The National Consumer Disputes Redressal Commission (NCDRC) has reiterated that mismatch in blood transfusion resulting in death of a patient will amount to medical negligence.
A bench of Justice RK Agrawal (President) and Dr SM Kantikar (member), therefore, directed a Thiruvananthapuram based private hospital to pay compensation of ₹20 lakh along with ₹1 lakh litigation cost to the family of a woman who died there in the year 2002.
“In the instant case wrong blood transfusion to Sajeena (deceased) was an error which no hospital/doctor exercising ordinary care would have made. Such an error is not an error of professional judgment but in the very nature of things a sure instance of medical negligence and the hospital’s breach of duty contributed to her death. Thus, we have no hesitation to hold the Opposite Party No. 1 (Hospital) and 2 (Doctor responsible for blood transfusion) liable for deficiency in service and the medical negligence,” the NCDRC said in its order.
The woman named Sajeena and her husband AK Nazeer were receiving infertility treatment at the Samad Hospital. After her laparoscopic surgery for fibroid uterus, Sajeena’s blood transfusion started but she immediately developed complications.
It was later revealed that this was a reaction to faulty blood transfusion since she was given B+ blood instead of O+. She died a few days later.
A complaint was filed by Nazeer before the State Commission, Kerala demanding a compensation of ₹45 lakh with an interest of ₹4.5 lakh towards medical expenditure.
The hospital, however, denied the allegation that there was any mismatch in blood transfusion. It was argued that Sajeena developed complications which were beyond their control and expectations.
It was stated that the complications were promptly treated but the patient developed DIC (Disseminated Intra Vascular Coagulation). The doctors also took expert consultation and the patient was referred to a higher centre immediately for better management, they said.
The commission allowed the complaint partially and directed the hospital and the doctors to pay ₹9.33 lakh to the family.
An appeal was filed by the erring parties against this order before NCDRC.
Referring to the findings of the State Commission, the NCDRC said that there were glaring lapses in the conduct of the hospital as it even failed to keep the transfusion register showing the number of bags, its date of receipt or use or disposal.
It held that the possibility of error in identification of the blood bags or identifying the patients was more.
“It should be borne in mind that the cross-matched blood received from the blood bank shall be transfused within reasonable time preferably within 24 hours. However, in the instant case, there is no record of when the blood was brought from the blood bank,” the NCDRC said.
It, therefore, concluded that wrong blood was transfused to the patient and the hospital staff is liable for the negligence.
The Commission further noted that if the transfusion reaction is suspected, the duty of the treating doctor is to immediately send the blood sample from a limb of the other side along with the blood for cross-matching.
“The urine to be examined for haemoglobinuria. Even, it was the legal duty of the blood bank to keep the pilot samples of the blood bags till the expiry of the blood i.e. 21 days. There was no such evidence that blood and urine samples were collected, any efforts made by OP-1 hospital to rule out haemolytic reaction,” the order said.
It added that the details of anesthesia and others entries as well as evidence of expert Dr Valentina showed that it was the case of transfusion reaction due to mismatched blood which resulted in severe bleeding.
The NCDRC, therefore, held that the State Commission had erred in quantifying the amount ₹9,33,000 as a compensation and the complainants deserve enhanced compensation.
“The Appellants shall jointly and severally pay Rs. 20 lakh as a compensation and Rs. 1 lakh towards the cost of litigation within 6 weeks from today to the parents of deceased Sajeena. Any delay beyond 6 weeks, shall attract interest @ 7% per annum till its realization,” it was ordered.
Senior Advocate Gopakumaran Nair and advocate Priya Balakrishnan appeared for the appellants.
Respondents were represented by Senior Advocate V Mohaha, and advocate Usha Nandini V.