Improper notings in medical records, and its fabrication / manipulation could raise suspicions and prove to be a costly affair, as seen in this medical negligence case.
Irrefutable Facts
The infant was delivered at full term at the hospital. The delivery was uneventful, and both the patient (infant) and the mother were discharged from the hospital.
After a month, it was noticed that the patient’s food intake had significantly reduced. A paediatrician was consulted; certain medicines were prescribed with an advice to be readmitted at the hospital.
Despite treatment, the patient’s condition continued to deteriorate, and passed away on the following day of admission. The hospital collected INR 1,300 for treatment.
Infant’s parents sued the paediatrician and hospital. It was alleged that despite patient’s critical condition, the paediatrician visited him only twice. The patient’s condition worsened, but the paediatrician did not disclose the actual cause to the attendant or refer him to another hospital for further management.
It was alleged that the blood investigation reports attached to the medical records were neither performed nor expenses were collected from the attendant. Furthermore, it was alleged that the paediatrician and the hospital conspired to prepare vague and false blood test reports to protect themselves.
Doctor’s Plea
The paediatrician stated in defence that upon admission, the patient was found to be malnourished with a blackish skin texture. Blood samples were immediately collected and sent for investigation.
The reports revealed septicaemia, and attendant was informed about the patient’s condition. However, the circumstances were beyond the control of any competent paediatrician, despite providing the best treatment to the patient.
Court’s Observations
The court perused the medical records and noted that the paediatrician had only 15–16 hours to manage the patient. The court wondered whether this was sufficient time for patient’s recovery.
The court observed from the Bed Head Ticket (BHT) that “various medicines and supply of oxygen and number of clinical and pathological investigations” were done. However, the hospital had charged only INR 1300. This fact raised suspicion, whether it was a deliberate attempt to protect the paediatrician and the hospital by “manufacturing” documents.
Hence, the State Consumer Commission sent the case back (remanded) to the District Consumer Court to decide on merits.
Prevention Is Better Than Cure
Manipulating / fabricating medical records is illegal and unethical. Once discovered, it damages the doctor’s / hospital’s credibility in the eyes of the court.
Source : Mritunjay Ghosh v/s Dr. Madhab Kumar Paul & Ors.
Get 7 days online access of this case’s abstract and its complete judgment for INR 250
Subscribe to this Case