A patient continued to suffer complications after gallbladder surgery, with later scans revealing ascites and a bile duct leak. Questions arose over the authenticity of a post-surgery USG report issued on plain paper without proper hospital authentication.
Irrefutable Facts
The patient with complaints of abdominal pain was admitted to the hospital. The doctors performed certain investigations. It revealed gall stones.
The patient underwent laparoscopic cholecystectomy. However, post-surgery her complaints persisted, and she consulted other doctors. The reports of USG performed at different centres revealed ascites in the peritoneal cavity; the MRI scan revealed a postoperative leak in the common bile duct (CBD) with gross ascites.
The patient was admitted to a higher centre for further management, where she died. The cause of death was reported as ‘Post-Cholecystectomy CBD Tear with Ascites with Hypovolemic Shock’.
Her family sued the doctors, alleging that they negligently performed the surgery, which caused injury to the CBD resulting in ascites, a fact that they admitted.
Doctors’ Plea
The doctors stated that post-surgery USG report was normal and did not report the presence of ascites. Furthermore, there was no post-mortem report to prove that the patient died of complications from a surgical injury.
Court’s Observations
The court perused hospital’s post-surgery USG report and observed that such an important report was issued on a simple piece of paper and not on the letterhead, and that too without the radiologist’s seal and signature and date.
Moreover, radiologist’s signature on the USG report and the affidavit filed in court were also different. The court observed that by way of such a report and his affidavit, the radiologist was trying to justify that there was no negligence on part of the doctors.
The court further commented that such a “report cannot be said to be genuine” and rejected the defence that there was no ascites post-surgery.
Both doctors were held negligent.
Prevention Is Better Than Cure
All the medical records of hospitals, such as investigation reports, surgery notes, consent forms, discharge summaries, and so on, should be written on appropriate stationery. Consultants, who visit a hospitalized patient to give a second opinion or perform an intervention / investigation, can document either on their own stationery or the hospital’s stationery. Ordinary blank papers should not be used for documenting except in emergencies. Courts and patients view this suspiciously.
Source : Maheshwari Nursing Home & Ors. v/s Hemant Kumar Jain & Ors.
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