The NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION (NCDRC) observed that the parents most stressful event in their life and cause for a major emotional crisis was that they lost their 28-year-old married daughter due to medical negligence and their son-in-law in a road accident.
Sajeena and her husband, A.K.Nazeer were undergoing fertility treatment at Samad Hospital, Thiruvananthpuram. Her reports revealed that she had to go through a surgery. After the surgery was performed, one of the doctors at the hospital asked for blood transfusion. After the blood transfusion was started, she immediately started having reactions.
It has been alleged that the said reactions took place due to the use of B+ positive blood instead of O+ blood. A consumer complaint was thus filed before the state commission. A few witnessess were presented, which included the doctors who performed the surgery. According to their statements, there was no need for blood transfusion and it was given without any consultation with them. One of the witnesses who appeared stated that there are some standard procedures which have to be followed in an event of wrong transfusion of blood such as stopping it immediately, sending the blood samples and the urine for further investigation, and to preserve the balance of blood in the blood bag. It was observed that nothing of that sort had been done, hence the state commission partly allowed the complaint and granted compensation of about 9 lakhs.
The NCDRC formed two issues:
(i) whether wrong blood was transfused, if yes- then whether hospital or the blood bank is
liable?
(ii) whether it was a transfusion reaction or DIC ?
The following issued were addressed on the basis of Dr. Valentina’s notes which were admitted as an exhibit. It was clear from her notes that wrong blood was transfused to the patient and the hospital staff is liable for the negligence. Further, it was a case of transfusion reaction due to mismatch blood.
It was observed as follows:
“Thus, in our view, the afore entry itself is sufficient to prove that mismatched blood was transfused to the patient. It was due to the blood bag which was kept in hospital refrigerator and transfused on the fateful day. Moreover, it was the duty of hospital to prove the wrong blood was issued from the Blood Bank , but the Apellant failed to prove it. Proper medical record has more importance. The finding of State Commission show the glaring lapses of the Opposite Parties Nos. 1 and 2, who have not kept the transfusion register showing the number of bags, its date of receipt or use or disposal. Thus, possibility of error in identification of the blood bags or identifying the patients was more……… We, further, note that the blood bag was kept in storage of the Hospital premise. 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 that when the blood was brought from the blood bank. Therefore, we conclude for Q. (i) that wrong blood was transfused to the patient and the hospital staff is liable for the negligence.”
NCDRC further relied on the Supreme Court judgment in the case of Postgraduate Institute of Medial Education
and Research Chandigarh vs. Jaspal Singh & Others wherein it has been held that mismatch in transfusion of blood resulting in death of patient is a case of medical negligence and in the instant case Sanjeeda has died due to the negligence of the hospital staff. NCDRC advised hospitals to investigate transfusion reactions:
“14.In most of the cases the hospital staff failing to respond to the signs and symptoms of a blood transfusion error. Thus the cause can be as simple as a breakdown in safety protocols or poor training. Though most hospitals and surgical centres have strict procedures on blood storage, but sometimes improper or poorly stored blood got issued. Reporting all transfusion-related adverse reactions to the Blood Bank promptly is more vital. Haemovigilance is the ‘systematic surveillance of adverse reactions and adverse events related to transfusion’ with the aim of improving transfusion safety. Transfusion reactions and adverse events should be investigated by the clinical team and hospital transfusion team and reviewed by the hospital transfusion committee.”
In light of the above, compensation of 20 lakh was awarded to the parents of the deceased.
case: M/S. SAMAD HOSPITAL vs. S. MUHAMMED BASHEER
http://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=0%2F0%2FFA%2F172%2F2012&dtofhearing=2022-05-25&fmt=P