Dr. S.M. Kantikar, Member1. The present Revision Petition has been filed by the Petitioners under Section 21(b) of the Consumer Protection Act, 1986 (hereinafter referred to as “the Act”) against the Order dated 31.08.2012 passed by the State Consumer Disputes Redressal Commission, Punjab (hereinafter referred to as the “State Commission”) in Appeal No. 1422 of 2009, whereby the Appeal filed by the Petitioners was dismissed and the Order dated 08.07.2009 passed by the District Consumer Disputes Redressal Forum, Ludhiana (hereinafter referred to as the “District Forum”) in Consumer Complaint No. 577 of 2006 was affirmed.2. Heard arguments from the learned counsel for both the sides.3. The matter relates to medical negligence / failure in duty of care on the part of the treating doctors at Employees State Insurance Corp. Hospital Ludhiana (for short “ESI Hospital”) resulting in death of the patient due to blood transfusion reaction.4. The District Forum vide its Order dated 08.07.2009 arrived at the findings that after transfusion of second bottle (unit) of blood the patient developed severe complications and died. The ESI Hospital had no proper facility for storage of blood bottles. On the principle of ‘res ipsa loquitor’, District Forum held the Petitioners negligent in administering mismatched or contaminated blood to the patient. The complaint against Petitioners was allowed and against Respondent Nos. 5 to 7 was dismissed. Compensation of Rs.500,000/- was directed to be paid by the Petitioners along with Rs.5000/- as litigation costs.5. The State Commission vide its Order dated 31.08.2012 dismissed the Appeal No. 1422 of 2009 filed by the Petitioner No.1. The relevant extracts of the appraisal made by the State Commission in its impugned Order are reproduced below:“21. The wife of respondent no.1, namely Smt. Ravinder Kaur admitted in appellant no.1-Hospital on 14.09.2004 for the operation of kidney stones and the doctors of appellant no.1-hospital asked for arraigning two bottles of blood from respondent no.6 and accordingly, two bottles of blood were arranged. The operation of the wife of respondent no.1 conducted on 18.09.2004 for Cholecystectomy by way of open surgery and one bottle was transfused and there was no reaction of that transfusion, which proves that the blood matched with the blood group of the wife of respondent no.1 and there was no complication or reaction. The second blood bottle was kept in appellant no.1-hospital, but it was not properly preserved, as there was no deep freezer or proper arrangement of safe storage of blood in the appellant-hospital. This Is clear from the reply of the appellant no. 1-hospital to the Para 8-C of the complaint In the reply filed on behalf of the appellant the reply was 'wrong and denied' and some of the facts pleaded in Para-8 of the complaint were denied for want of knowledge. There was no specific denial, nor was it reiterated that there is deep freezer or proper arrangement of proper storage of blood in appellant no.1-hospital. The second blood bottle was in the custody of appellant no. 1-hospital and on 21. 09. 2004, the second blood transfusion was carried out and within five minutes of the transfusion of blood, the wife of respondent no.1 felt back pain, shivering, palpitation etc. and it was due to the wrong transfusion of blood and blood reaction. On 22.09.2004, the said patient developed Jaundice, breathlessness and fall in Blood Pressure and appellant no.1-hospital referred the patient to C.M.C. & Hospital, Ludhiana. As per the Medical Summary Ex.C-11 recorded on 22.09.2004 by the doctors of respondent no.5-C.M.C. & Hospital, Ludhiana, it was observed as follows:-"This lady had open cholecystectomy on 18.09.2004 from ESI hospital (for chronic cholecystitis and cholelithiasis). She remained weIl for 2 days after that when she was transfused blood on 21.09.2004, patient developed severe back pain 5 minutes after starting transfusion followed by shivering, palpitation, ghabrahat. Patient had 2 episode of vomiting, non-bilious, non-projectile, containing watery fluid but she continued to have ghabrahat and sweating intermittently".22. Under the head "Final Diagnosis", it was mentioned as follows:-POST CHOLECYSTECTOMY WITH JAUNDICE? SEPSIS ? POST TRANSFUSION REACTION ? ANAEMIA".23. Thus, from the above, it is clear that it was a blood transfusion reaction which led to severe back pain, shivering, palpitation, uneasiness and jaundice. Respondent no.5 treated the patient for the said diseases, but it was too late and she died on 24.09.2004. The reaction on transfusion of second blood bottle clearly proves that before transfusion of the said bottle, it was not assured that the blood is matching and during the period from 14.09.2004 to 21.09.2004, it was kept in safe storage and has not contaminated, but nothing such was done and once there were no proper storage facilities available with the appellants, then it was more on the part of the appellants to make sure that the blood which is to be' transfused is safe and is matching to the blood group of the patient and has not got contaminated in the meantime, because for seven days it was not used. Thus, the negligence of the doctors of the appellant no. 1-hospital is proved, as they did not bother to take necessary care and precaution before transfusion of blood. This is a case of gross negligence and no expert opinion was required and it cannot be termed as any complication arising out of the operation. The order of the District Forum is very detailed and is a speaking order and the facts and evidence has been discussed in detail and, as such, there is no ground to interfere with the same.(emphasis supplied)6. We have perused the material on record, including inter alia the Orders of the District Forum and the impugned Order of the State Commission.7. After our thoughtful consideration, to recollect the brief facts, on 14.09.2004 Smt. Ravinder Kaur, wife of Moninder Singh - (the Respondent No. 1), (hereinafter referred to as the “patient”) was admitted to Employees State Insurance Corp. Hospital, Ludhiana (for short ESI – Hospital - the Petitioner No. 1) for the operation of gall stones (the District Forum wrongly mentioned it as ‘Kidney Stones’). The patient was anemic, therefore as advised by the doctors, the Respondent No.1 arranged 2 bottles of blood from District Red Cross Society-cum-Red Cross Blood Bank (the Respondent No. 6). On 14.09.2004, one bottle of blood was transfused and the Cholecystectomy operation was performed on 18.09.2004. After 3 days on 21.09.2004, in the morning the second bottle of blood was transfused in the patient, but at about 9:40am, the patient developed shivering and blood reaction. The next day on 22.09.2004, she developed jaundice, tachycardia, and breathlessness and fall in B.P. and was put on Oxygen. The doctors provisionally diagnosed it as ‘Toxic Hepatitis, blood reaction’ and immediately referred the patient to C.M.C. Hospital, Ludhiana (hereinafter referred to as “Respondent No. 5”).However, the patient died on 24.09.2004. The cause of death mentioned by CMC Hospital was “Post Cholecystectomy Jaundice with shock, Sepsis, Blood transfusion reaction”.8. The main grouse of the complainant was that there was no proper arrangement for safe storage of blood at Petitioner No. 1 Hospital. The 2nd unit of blood was not stored properly for 7 days due to which it got contaminated and the same was transfused in the patient causing severe complication and ultimately death.9. It is pertinent to note that the case of Complainant was not a case of faulty operation or any complication arising out of the operation. We note, admittedly, in the hospital one unit of blood was transfused on 14.09.2004 and the 2nd unit was transfused after 7 days i.e. on 21.09.2004 at 9.40 AM and immediately the patient showed transfusion reaction.10. In addition, the referral letter issued by the ESI Hospital and as per the Medical summary (Ex-C-11) of CMC Ludhiana (Respondent No. 5) that it was the case of blood transfusion reaction. The ESI hospital failed to produce cogent evidence that for 7 days where and how the 2nd unit of blood was stored. The blood unit should have been stored at 40 C in a specialized refrigerator having alarm facility (blood storage refrigerator). It was the duty of hospital to send the the unused blood unit back to the blood bank for proper storage and called whenever it was needed. If the blood is not stored properly it may deteriorate by hemolysis and/or contaminated. If it was stored in the freezer hemolysis (destruction) of blood will occur and transfusion of such blood evokes fatal transfusion reactions.11. The District Forum and the
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State Commission held that the two blood units were issued by the Blood Bank (Respondent No. 6) on 14.09.2004 and one unit was transfused on 14.09.2004. The 2nd unit of blood was used after 7 days of its issuance which caused transfusion reaction and death of the patient. The Opposite Party No.2 hospital failed to prove that the 2nd unit of blood was preserved properly and there was no hemolysis after 7 days before transfusion done on 21.09.2004.12. The State Commission has passed a well-appraised reasoned Order. It has concurred with the findings of the District Forum. We do not find any crucial error in appreciating the evidence by the two fora below. In the exercise of the Revisional Jurisdiction of this Commission we do not find jurisdictional error, or legal principle ignored, or miscarriage of justice which needs interference with the impugned Order of the State Commission.13. The revision petition, being ill-conceived and without merit, is dismissed.