IMPORTANT POINT
In a medical negligence case, the doctors and the concerned hospital have a responsibility to correctly explain their conduct and their records should prove that there was no negligence on their part.

P.D. Shenoy, Member—A healthy well nourished lady, Mrs. Jayshree Lohakpure aged 38 years was admitted to the hospital on 23.2.1995 for hysterectomy and taken to the operation theatre at 1.40 p.m. on 24.2.1995 and declared dead at 3 p.m. before the commencement of surgery in the presence of anaesthetist, gynaecologist, nurses and lastly a surgeon and a chest specialist who came to the Operation Theatre (OT) a few minutes before her death. Can this be considered as a case of medical negligence? A detailed analysis of the case leaves no room for doubt.

Case of the complainant

2. Complainant No.1 is the husband of the patient Jayshree Lohakpure who is survived by her two children. Complainant No. 2 and No. 3 have filed this complaint through their next best friend and guardian, complainant No 1.

3. On the recommendations of Dr. Chandavarkar. Opposite Party No. 3 (OP No.3) was admitted to Smt. Suniti Devi Singhania Hospital and Medical Research Center, Thane. She was declared dead around 3 p.m. on 24.2.95 even before the actual surgery was commenced because of the negligent manner in which anaesthesia was administered by Dr. Page and also because of inadequate and negligent emergency medical aid provided by the opposite parties.

4. Mrs. Lohakpure having menstruation problem for a month consulted OP No. 3 who recommended hysterectomy. As the test results were satisfactory, surgery was fixed at 2 p.m. on 24.2.1995 and was admitted on the previous day to the hospital. Necessary fees were paid by the complainant. To get best possible treatment, the patient was admitted into the best class as per the booklet printed by the hospital titled ‘Patient guide and some useful information.’

5. Mrs. Lohakpure was prepared for surgery and taken to the OT at 1.30 p.m. At 1.45 p.m. just 15 minutes before the commencement of surgery Dr. Page, anaesthetist met the patient for the first time. After perfunctorily asking the patient some questions about her health, Dr. Page at 2.15 p.m. started administering her anaesthesia. Dr Chandavarkar, Gynaecologist arrived at 2 p.m. All her vital organs at that time were normal. Two nurses Mrs. Anni Polas and Mrs. Vatsama Ratankumar were also present. Though Mrs. Lohakpure was admitted to the hospital on 23.3.95 a day prior to the operation, Dr. Page did not examine her nor did he conduct preoperative anaesthetic check up. At 2.15 p.m. Dr. Page and Dr. Chandavarkar OP No.2 & 3, started preparing her for the operation. Dr. Page tried to insert the endotrachea tube but he was unable to do so. He then removed the tube and put her on artificial respiration. All her vital signs at that time were normal. He mentioned the difficulty in inserting the tube to Dr. Chandavarkar and Nurse Anni Polas heard him say this as well. Despite this difficulty Dr. Page continued his attempts under anaesthesia. The operation was not a vital life saving procedure, which could have been easily postponed. According to Dr. Page the reason that he could not insert the tube was because of the, “composition (arrangement anatomy) of the physique (body) of the patient and the Swaryantra (throat) the said tube could not go into the Swaryantra (throat).”

6. Dr Page despite the failed attempt, tried to insert the tube once again in exactly the same manner. He made no effort whatsoever to make an attempt which would overcome the alleged abnormality which he himself had stated only minutes ago existed nor did he adopt a different method to put her under anaesthesia. Forceful effort to reinsert the endotrachea tube caused laceration on her upper lip. As it was not an emergency procedure and as Dr. Page found an abnormality in the physique, the surgery could have been easily postponed. Instead a second and negligent attempt was made and due to this she was deprived of sufficient oxygen. Consequently, when he finally put her back on artificial respiration her pulse had reduced and her heart completely stopped at 2.30.p.m. Though the situation was d