Consent is an important aspect of healthcare delivery. However, there are times when delivering critical care takes precedence over taking consent. This case is an apt example of the fact.
Irrefutable Facts
The patient was admitted to the hospital in labor. The gynaecologist performed forceps delivery; there was a last-minute complication and hence, episiotomy was performed.
On the following day post-delivery, pus started oozing from the surgical scar. The patient complained of difficulty in urinating and defecating. The gynaecologist re-sutured the surgical site and adopted conservative management, but to no avail.
One surgeon diagnosed the patient with a complete perineum tear, treated the wound and advised another surgery. The patient sought Discharge Against Medical Advice (DAMA), got admitted to another hospital, underwent a three-stage surgery and was discharged satisfactorily.
The patient sued the gynaecologist and hospital.
It was alleged that the doctor negligently performed episiotomy causing injury and damage / rupture to the anus resulting in unbearable pain. She also alleged that no immediate steps were taken at the hospital to treat the infection. Rather, they waited for the surgeon who was on leave and was supposed to operate. This delay worsened patient’s condition, which necessitated the three-stage surgery.
It was also alleged that the patient was neither advised nor referred to a higher centre.
Doctor’s Plea
The gynaecologist stated in defence that episiotomy was performed to create space for baby’s delivery. The doctor pointed out that perineal tear was a common post-operative complication. The infection was diagnosed on time, the patient was given antibiotics and another surgery was advised after the infection was controlled.
The hospital stated in defence that the patient was referred to one higher centre where experts were available, but the attendants refused and preferred to go to a private hospital.
Court’s Observations
The court, on perusal of medical literature and medical records, observed that baby’s head was at the outlet but was not able to come out, and the patient was not able to strain any further; therefore, to save the baby, gynaecologist had to apply outlet forceps after giving episiotomy. The court held that this procedure adopted by the doctor was in the interest of patient and her child.
The court further perused medical literature and expert opinion, observing that “complete perineal tear is always a possibility in certain cases of forceps delivery”, and the patient was properly managed with antibiotics and re-suturing. Hence, the court rejected the allegation that a complete perineal tear resulted from insufficient care.
The court could not find any mention of an advice for referral to a higher centre or that the attendants refused to follow such advice in the discharge summary. Hence, the court rejected hospital’s defence in this regard.
The court pointed out that the patient was diagnosed with a complete perineal tear and hence, the hospital should have immediately shifted her to the higher centre and that such a decision does not require consent of the patient / attendant as the interest of patient gains significance.
The court drew an adverse inference against the hospital for waiting for the surgeon to return, thereby wasting 3 days, resulting in the patient undergoing a three-stage surgery.
Hence, the hospital was held negligent.
Prevention Is Better Than Cure
- Patient interest should be paramount and fully protected while delivering healthcare services. Any procedural protocol that tends to interfere with the patient’s interest in any way can be safely ignored. The Hon’ble Madras High Court has reiterated this dictum. Further, no consent from the patient / attendant is required to transfer the patient to another facility when indicated.
- All interventions must be performed when indicated. Any delay should only be for a justified medical reason. The reasons should be documented and also communicated to the patient / attendants.
Source : S. Bhanupriya v/s The State of Tamil Nadu & Ors.
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