Angel Arulraj, Member
1. The complainant is a married woman aged 40 years with no children. She developed a lump in the left breast, which was referred by her family Doctor, Dr. P.K. Srinivasan, to the second opposite party at Malar Hospital (1st opposite party) for a thorough examination and diagnosis and treatment on 25.7.1992. The complainant was examined by a physician at Malar Hospital who prepared the consultation report and later signed by Dr. Ravindra Padmanabhan, 2nd opposite party. The 2nd opposite party is a Consultant Surgeon at Malar Hospital. The lump in left breast was diagnosed as "FIBROADENOMA" and the complainant was advised MAMMOGRAM and excision biopsy. On 31.7.1992, Mammogram was done in Malar medical Imaging Centre at Century Plaza, No. 562, Anna Salai, Madras-600018. The report was "Two well defined Nodules in the left breast - feature of FIBROADENOMA". On 3.8.1992, the complainant was admitted in the Malar Hospital for removal of lump in the left breast [FIBROADENOMA LEFT BREAST]. On 4.8.1992, Ultra Sound Study of the whole abdomen was done and the report was "normal study of the whole abdomen". The complainant was operated by Dr. Ravindra Padmanabhan, 2nd opposite party on 5.8.1992. After regaining consciousness, the complainant was shocked by the information that her uterus was removed. She suffered from severe post-operative complications such as pus in the vagina, severe pain in her body and limbs, and difficulty in passing urine and motion. In spite of her abovesaid complications, the complainant was discharged on 10.8.1992. The Discharge Summary dated 10.8.1992 indicated that on 5.8.1992 (1) Abdominal Hysterectomy with right Oopharectomy, and (2) excision of the lump in her left breast done. In spite of the Ultra Sound Study of the whole abdomen as normal, the discharge summary (Ex. A-4) revealed second-degree prolapse of the uterus apparently to cover the gross negligence and professional misconduct of the 2nd opposite party in performing abdominal Hysterectomy. The discharge summary states "POST OPERATIVE PERIOD UNEVENTFUL", in spite of the complications the complainant had. The pathology report (Ex. A-6) dated 10.8.1992 did not indicate anything abnormal or immensely dangerous as to warrant urgent removal of the entire uterus and the right ovary. The complainant had severe pain on account of pus in the vagina for which she was treated on 18.8.1992 without anaesthesia under general anaesthesia by the 2nd opposite party. Even eight months after surgery, the complainant suffered from body pain and difficulty in passing urine and motion. The complainant further alleged that even if she had prolapse, the 2nd opposite party adopted the abdominal route instead of the vaginal route in removing the uterus and a wrong surgical incision in doing Abdominal Hysterectomy. The complainant was asked to pay for equipments used such as bed pans, urinals, surgical gloves, masks, etc. bought from the 1st opposite party and they were not returned to her at the time of discharge. The complainant submitted that due to the Hysterectomy done she was suffering and was rendered incapable of bearing any children in the future. She prayed for:
1. Rs. 10 lakhs as compensation from the 1st and 2nd opposite parties for the loss, mental agony caused by negligence and professional misconduct.
2. to pay Rs. 1.5 lakhs for the expenses incurred; and
3. the cost of the complaint.
2. The 1st opposite party in its written version submitted that the hospital only offered the premises for the use of the Consultants and the 2nd opposite party is only a consultant and not employed by them. The hospital charged only for the facilities provided and had no role in the treatment given by the 2nd opposite party. It is entitled to charge for all surgical disposables and medicines prescribed by the treating Doctor and there was no question of providing them at free of cost. The first opposite party further stated that it was not vicariously liable for the Deficiency of Service by the 2nd opposite party as alleged by the complainant and prayed that the complaint may be dismissed with costs.
3. The 2nd opposite party in his written version contended that he is a well respected senior surgeon with excellent reputation. He is competent to perform "Uterus removal operation" and, in fact, many leading Gynaecologists call him during operation to manage with cases of complications. The complainant was referred to him by her family Doctor, Dr. P.K. Srinivasan who in his introductory letter (Ex. B 1) dated 20.7.1992 clearly stated that the "lump in her left breast has progressively enlarged and gives pain. She is also having severe painful profuse bleeding P.V. for which she has consulted the Gynaecologist and has been advised Hysterectomy immediately. In view of the difficult financial condition of the family at present, kindly consider combining the two procedures in one sitting to reduce her expenses." He stated that this letter revealed:
(a) that the complainant was well aware about the problems in her uterus even before the operation; and
(b) complainant's Family Doctor's (senior doctor of eminence) confidence in this opposite party's competence and skill to perform the required surgeries.
As admitted by the complainant herself, she had consulted a Gynaecologist before going to Dr. P.K. Srinivasan, and this Gynaecologist advised immediate Hysterectomy. This again reveals that she was having complications in the uterus and about which she had been made aware of that she consulted quite a few other doctors.
Before the complainant underwent surgery, both the complainant and her husband had consented for the operation in writing on 4.8.1992. In this consent letter, the nature of operation in layman’s terminology was given as "Removal (1) Breast lump and uterus". The 2nd opposite party denied all the allegations made against him. The whole intention of the complainant was to blackmail the 2nd opposite party. The complainant's statement that in the post-operative period the 2nd opposite party tried to drain the pus without giving general anaesthesia was because the complainant had a full stomach on that day. The 2nd opposite party asked her to come on an empty stomach the next day and the pus was drained under general anaesthesia. Regarding the allegations made against the midline incision for abdominal Hysterectomy, the opposite parties stated that he adopted the correct and the proper method.
From the book General Surgery by Dr. John J. Byrne MD. Professor of Surgery, Boston University, School of Medicine, the 2nd opposite party quoted the following:
"Many surgeons favour paramedian incisions because they feel it increases the exposure to that side of the abdomen. Paramedian incisions, however, have all the disadvantages of midline incisions. Since they are made against the lines of tension of the abdominal wall, they require more time to perform and to repair, and, more importantly, they do not lead to, as strong a closure as the vertical midline incision. Several reports have documented an increased incidence of wound dishiscence and ventral hernia formation with paramedian as compared with transverse or midline incisions.
(1.2) We use this incision only in patients with a prior paramedian incision".
The 2nd opposite party wanted the whole issue to be discussed with a Doctor of equal or more competence. He prayed for dismissal of the case with costs.
4. The points for determination are:
(1) whether there was any negligence or deficiency of service on the part of the 2nd opposite party; and
(2) if so, the amount of compensation, the complainant is entitled to.
5. Point No. 1: We heard both sides and perused the available records. The learned Counsel for the complainant exonerated the 1st opposite party Malar Hospitals from his allegations and also stated that he was not relying on the depositions of Dr. Sridhar (PW1) for his case. So, the case against the 1st opposite party stands dismissed as withdrawn.
The main case of the complainant was that the complainant had no disease in the uterus or prolapse uterus and a normal uterus was removed without the knowledge of the complainant. The learned Counsel for the complainant contends that as per Shaw's Text Book of Gynaecology page 352. "The normal position of the uterus is one of anteversion". He further stated that in prolapse, "Uterus is invariably retroverted" [page 364 of Shaw's Text Book of Gynaecology]. He further contends that the ultra sound study of the whole abdomen (Ex. A3) done on 4.8.1992 showed "the uterus is anteverted, measures 10.4x5.4 cms and appears bulky. The endomentrium is slightly thickened (pre-menstrual phase) the myometrium is normal Cervix and vagina are normal". He further stated that as per Ultra Sound Study, the uterus was anteverted and normal in size. There was no abnormal studies in the Ultra Sound. So, the complainant had no prolapse uterus. According to the complainant, a normal uterus was removed without the consent of the complainant which amounted to gross negligence and deficiency of service on the part of the 2nd opposite party.
6. The learned Counsel for the 2nd opposite party contends that the complainant was referred to the 2nd opposite party by her family Doctor, Dr. P.K. Srinivasan. Ex. B1 letter shows that the patient, in addition to the breast lump on the left side, had bleeding and she was seen by a Gynaecologist who advised Hysterectomy. The complainant was well aware of her disease in the uterus and also gave consent for removal of the lump in the left breast and removal of uterus by abdominal Hysterectomy. The nature of surgery namely excision biopsy of lump in the left breast and abdominal Hysterectomy were explained to the complainant and her husband, and their con sent were obtained before the surgery. The consent letter Ex. B 6 was signed by both the complainant and her husband. The learned Counsel contended that the Gynaecologist's report stating the diagnosis of second degree prolapse was lost and so could not be produced in the Court. The 2nd opposite party did the operation on the basis and advice of the Gynaecologist's report and Dr. P.K. Srinivasan's letter (Ex. B1). He did it in one stage as requested in Dr. P.K. Srinivasan's letter. The learned Counsel further added that there was no purpose in removing the normal uterus for it cannot be transplanted in another woman as in the case of kidney or heart or eye transplants. The complaint was a false and fabricated one and prayed dismissal for the same with costs.
7. General surgeons are competent to do Hysterectomy. Many times, they are called to help the Gynaecologists in cases of complications because of their experience in all the fields. The very fact that complainant's family Doctor had referred the complainant to the 2nd opposite party shows his confidence in the 2nd opposite party. The 2nd opposite party in his deposition (RW1) said that he did not do vaginal examination prior to the operation for the following reasons:
"1. the patient's complaints were clear and explicit;
2. the patient had already seen a Gynaecologist and was advised a Hysterectomy;
3. this was corroborated by the letter from the family Physician, Dr. P.K. Srinivasan;
4. in deference to the sensitivity of the lady patient."
The 2nd opposite party depended on the Gynaecologist's report and Dr. P.K. Srinivasan's reference letter and the patients explicit complaint and after investigations conducted the surgery abdominal Hysterectomy.
Dr. P.K. Srinivasan, a Physician, the family Doctor of the patient for many years, in his reference letter Ex. B-l says, "She is also having severe painful profuse bleeding P.V. for which she says she has consulted the Gynaecologist and has been advised Hysterectomy immediately." As a family Doctor, Dr. P.K. Srinivasan must have known about the patient's complaint and because it needed surgery (and also advised by the Gynaecologist's examination report) he sent the patient with his letter to the 2nd opposite party recommending Hysterectomy for the complainant. The complainant must have known about the contents of the letter and the treatment recommended by her family Doctor.
Ex. B-2(a) is "Consent for medical and surgical treatment". This record was signed by the complainant and her husband. The 2nd opposite party says in his deposition that the nature of surgery and the pros and cons were explained to the complainant and her husband before they signed their consent for the operation.
It is very obvious, Sonogram study was done in this case to rule out any Pathology in the uterus in addition, as the complainant had "severe painful profuse bleeding P.V." - as per Ex. B1. Sonogram is not an investigation to diagnose prolapse uterus. Ultra Sound Study is not 100% accurate, as it has many fallacies. The accuracy depends on the machine used and the man behind it and also documentation on the film from the monitor. In first and second degree prolapse uterus, the descent of the uterus is not permanent. It recedes when the patient rests and comes down when the patient strains. In this case, when the complainant lay down for Sonogram, the uterus could have receded or the complainant could have pushed it up. The position of the uterus anteversion or retroversion is not the point for consideration to know whether the complainant had prolapse uterus or not. To say that the complainant had no prolapse uterus,, Ultra Sound Study is not the last ward.
On going through the medical report given by Dr. Sridhar-marked as Ex. A13- the report says,
"………The patient says she had not planned to have Hysterectomy, but was told to undergo the surgery to remove her uterus a day before her scheduled breast surgery by the surgeon Dr. Ravindra Padmanabhan at Malar Hospitals.,..."
In all hospitals, the patients who are posted to undergo surgery are being prepared one or two days earlier. In this particular case, the complainant must have been prepared the previous night and the early morning of the day of operation. The duty Nurse must have shaved and cleaned the areas viz, (1) left breast (chest); and (2) whole of abdomen. So, the patient must have known about the abdominal surgery beforehand. In the above circumstances, the complainant's statement that, "after she regained her consciousness, the complainant was informed that her uterus has been removed and the complainant was shocked to learn about this as she had not been told that her uterus was being removed" is a blatant lie.
The management and treatment for all degrees of prolapse uterus is influenced by many factors like child bearing age, menopause and associated diseases of the uterus. Shaw's Text Book of Gynaecology [page 380] last paragraph C, says that,
"(c) a patient with prolapse who also suffers from dysfunctional uterine bleeding or has uterine fibroid which by itself warrants a Hysterectomy" -The route of approach in Hysterectomy, either abdominal or vaginal is always decided by the operating surgeon."
Ex. A5 is the Surgical Pathology Report. This report is a histological study of the tissues removed at the time of surgery. This is an important record that reveals the true nature of the disease of the organs removed at the time of surgery. The sections of tissues are preserved for many years for future references of the concerned case. It contains the following:
A. Specimen of uterus, cervix. Right tube and ovary totally measuring 9.5 x 4.5 x 3 cms. Cervix appears normal. Uterus is enlarged bossalated and cut section shows a large well demarcated whorled whitish mass 3 cms diameter.
Right tube is 3.5 cms. Right ovary is 4 x 2 x 1.5 cms. Cut section shows cysts.
1. CERVIX: Section shows mildly acanthotic ectocervix and endocervix with marked papillary proliferation of the lining epithelium. Submucosa shows diffuse dense lymphocytic infiltrate.
2. UTERUS: Section of uterus shows endometnum in proliferative phase with tubular glands and cellular stroma. The myometrium reveals a well demarcated tumor composed of interlacing bundles of spindle cells with uniform cigal nuglei.
3. TUBE: Section of right fallopian tube appears histologically normal.
4. OVARY: Section shows ovarian tissue with many cystic follicles lined by stratified thecal cells. Surrounding stroma is dense and cellular.
1. CERVIX: Severe chronic non specific endocervitisn with ectocervicitis.
2. UTERUS: Proliferative phase endometrium. Benign intramural Leiomyema.
3. TUBE: RIGHT: Normal.
4. OVARY: RIGHT: Follicular cyst.
5. LUMP: Benigh fibroadenoma of breast-Mixed intracanalicular and pericanalicular pattern.
(All underlinings ours)"
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Pathology report is the strongest evidence that the complainant had disease in the uterus, namely, fibroid uterus and chronic cervicitis. Cervicitis is found in all cases of prolapse uterus. So the patient had disease in uterus which needed Hysterectomy. The complainant admits in her complaint that on consultation with her physician Dr. P.K. Srinivasan, she was referred to Malar Hospitals. So, the reference letter by Dr. P.K. Srinivasan, Ex. B1, must be true. This fact was supported by the evidence of Dr. P.K. Srinivasan RW 2, admittedly the consultant physician in the complainant's case. He had clearly indicated in his letter Ex. B1 that the complainant had consulted the Gynaecologist and had been advised Hysterectomy immediately. The 2nd opposite party RW 1 must be telling the truth when he says. "1. The patient's complaints were clear and explicit, 2. The patient had already seen a Gynaecologist and was advised a Hysterectomy; 3. This was corroborated by the letter from the family Physician, Dr. P.K. Srinivasan;" Because the Gynaecologist examination report was lost and it was not attached to the discharge summary report Ex. A4 or to the consultation report Ex. A-l and because the word "prolapse uterus" was not mentioned in the consultation report Ex. Al and mentioned only in the discharge summary report Ex. A4, the complainant took advantage of the situation and filed a false complaint. For the above reasons, I find no deficiency in service on the part of the 2nd opposite party. This point I find in favour of the 2nd opposite party. 8. Point No. 2 : On account of my above finding, the complainant is not entitled to any compensation. This point, I find in favour of the 2nd opposite party. 9. In the result, the complaint is dismissed with a cost of Rs. 1,000/-. Complaint dismissed with cost.