In medical practice, compliance goes beyond clinic displays and extends to every prescription as a legal record. Courts now closely assess documentation, statutory disclosures, and evidence-based treatment when judging medical negligence.
Experience alone is no longer a defence — accountability lies in written proof.
Irrefutable Facts
The patient consulted the doctor with complaints of joint pain. The doctor, based on clinical examination, arrived at the diagnosis of rheumatoid arthritis and prescribed some medicines.
Despite five follow-up visits, her condition did not improve. No investigations were advised.
Five days after the last consultation (fifth one), the patient’s health deteriorated significantly, with a week-long fever, occasional cough, and expectoration. Consequently, the patient consulted a second doctor who promptly advised immediate hospitalization.
The patient was admitted to a hospital in an emergency for shortness of breath and drowsiness and was put on a ventilator, but her condition continued to deteriorate. After a few days of hospitalization, the patient suffered cardiac arrest. Despite initiating CPR, she could not be revived. The cause of death was reported as Bilateral Pneumonia and Acute Respiratory Distress Syndrome (ARDS).
The doctor was sued by patient’s family. It was alleged that he neither himself provided proper care to the patient nor referred her to an appropriate speciality nor recommended any investigations.
It was also pointed out that the doctor had not mentioned his registration number on the prescription.
Doctor’s Plea
The doctor pointed out that the patient consulted him with a history of chronic joint pain. Clinical examination indicated arthritis. However, she ever gave a history of fever or cough.
The doctor stated that he intended to advise investigations during every follow-up but was constrained by the patient’s financial condition. Further, the patient insisted on treatment based on her previous investigation reports, and accordingly, she was managed. The doctor also stated that the registration number and his educational qualifications were displayed in the chamber.
Court’s Observations
The court perused the medical literature and found that certain medications, especially in treating Rheumatoid arthritis, need regular clinical tests and investigations. The court observed that in the instant case, the doctor did not advise investigations and merely relied on his 35 years of experience to diagnose the patient, a practice that did not align with the accepted standards.
The court observed from the defence of the doctor that he had prescribed medicines based on the patient’s previous test reports, citing the patient’s financial constraints. However, the court rejected this defence outright because the previous investigation reports were not referenced in the prescription.
The court also observed that the nondisclosure of the registration number and not mentioning the patient’s history on the prescription was another negligent act on doctor’s part.
Therefore, the doctor was held negligent.
Prevention Is Better Than Cure
- As per the IMC Regulations 2002, every registered medical practitioner is obligated to display their qualification and registration number, issued by the Medical Council of India, in their clinic as well as on all prescriptions, certificates, and money receipts provided to the patients.
- Doctors’ experience and expertise increase with time, making their clinical sense more accurate and dependable. The clinical acumen of the doctor had a greater role to play earlier. But with the cases of medical negligence increasing nowadays, courts expect that greater importance should be given to investigations and diagnosis / treatment should be evidence-based, as illustrated in this case.
Source : Somnath Pal & Ors. v/s Dr. Somendra Saha
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