Evidently, patient’s history and past medical records plays a vital role in delivering medical care. At time, as in this instance, patient’s / attendants do not reveal either the history or present past medical records. What should doctors and hospitals do in such cases?
Irrefutable Facts
The patient with complaints of headache and dizziness consulted the neurosurgeon and was admitted to the hospital. MRI revealed Pituitary Gland Tumor (PGT). The neurosurgeon performed pituitary microadenoma; the patient was discharged with an advice to take pain killer tablet twice daily for two weeks.
Subsequently, the patient suffered from Malena; he was admitted twice to the hospital and consulted the gastroenterologist. Several investigations were performed but the cause of active GI bleed could not be diagnosed.
On both occasions, the patient was managed conservatively and discharged after the bleeding stopped. After third discharge, the patient suffered a stroke. He took treatment at different hospitals, where investigations revealed Hepatic Encephalopathy, sepsis, and multi-organ failure. He was managed conservatively but died due to cardiac arrest.
His family sued the hospital and doctors. It was alleged that the painkiller was prescribed without considering the patient’s history of GI bleed or Malena, and without evaluating patient’s GI system.
It was also alleged that the attendants were not informed about the prescribed drug’s possible side effects. Furthermore, due to GI bleed, the patient was transfused twenty-eight units of blood / plasma, permanently affecting his immune system which hastened his death.
Hospital’s Plea
The hospital stated that during first admission, the patient neither gave a history of Malena nor showed previous medical record to the treating doctors. It was pointed out that during subsequent admissions, the patient was thoroughly investigated, but the cause of bleeding could not be detected.
Later on, the patient disclosed his past history of repeated GI bleed. However, the source of bleeding could still not be traced.
Court’s Observations
The court opined that the patient was elderly and a known case of long-standing diabetes mellitus and hypertension, thus substantially at higher risk and could suffer a stroke at any time.
The court also noted that such a patient died almost one year after his discharge from the hospital, and during that period, he took treatment from different hospitals. Therefore, the cause of death cannot be attributed to the hospital and the treating doctors.
Hence, the court dismissed the case against the hospital and doctors.
Prevention Is Better Than Cure
- Every effort should be made to obtain the correct and complete history of the patient. Patient’s previous medical records must be perused. If later on, the patient discloses, or the doctor discovers the correct history or suspects that the patient is concealing or trying to conceal history or medical records, this should be duly documented in medical records.
- Proper efforts must be made in accordance with medical science to arrive at a final diagnosis. But there is always a possibility that in spite of genuine and proper attempts, patient’s condition / ailment may remain obscure and undiagnosed. Courts will not hold this as negligence.
Source : Deepak Gupta & Ors. v/s Indraprastha Apollo Hospitals & Ors.
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