After improper consent, ill-prepared medical records account for a very large number of medical negligence cases. Perhaps that’s why it is often said: ‘Good medical records, good defence; no medical records no defence.’
Irrefutable Facts
A toddler was bitten by the snake in her right thumb and was taken to hospital where the doctors managed her conservatively. Unfortunately, neurotoxins spread due to the snake’s venom and gangrene set in her right thumb; it had to be amputated.
The patient was managed conservatively, put on a ventilator and later discharged satisfactorily.
Her parents sued the hospital. It was alleged that the doctors did not treat the child properly as a paediatrician or other relevant specialists were not consulted. It was further alleged that a black thread was tied in patient’s right thumb, and due to such non-specific treatment, gangrene developed.
Doctor’s Plea
Refuting the allegations, the hospital authorities pointed out that the child was brought with a black thread tied on her right thumb near the site of snake bite to stop the spread of venom which gradually led to the development of gangrene.
It was stated that the patient was attended by a team of doctors consisting of causality medical officer, chief anaesthetist, child specialist, surgeon and orthopaedic surgeon.
Court’s Observations
The court perused bed head ticket / medical records and could not find any noting about a black thread already tied to patient’s right thumb at the time of admission. Therefore, this defence was rejected.
The court observed that even after perusing medical records, it could not draw any conclusion about the type of treatment given by doctors to stop the secondary infection of gangrene from developing despite multi-specialities being engaged in delivering patient care.
The hospital was held negligent.
Prevention Is Better Than Cure
- Note down the history in medical records diligently and in detail while admitting patient; anything unusual must be expressly noted. Failure to do so could prove costly in legal proceedings. This case illustrates the aforesaid aptly.
- Referrals and joint consultations with the relevant specialities are an integral part of modern practice. Referring the patient to an appropriate consultant, holding joint consultations when the situation demands and / or taking a second opinion from a senior and experienced consultant of the same speciality is always appreciated by the court. These are rather mandatory in situations when the patient is critical, suffering from a rare disease, some critical decision has to be taken, there is a dilemma on the course to be followed, and so on. The steps taken in this direction, as well as the opinion of the other consultants, must be specifically documented.
Source : Chief Medical Officer, Nehru Satabdi Central Hospital & Ors. v/s Puja Sahu
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