“The treating doctors failed to observe the protocol which resulted in pancreatitis and consequential death. Mental agony of the complainant and other dependents of the deceased, one can imagine, especially so when she was only 45 years old,” the commission said.
The panel’s judicial member, N P Kaushik, was hearing a plea of St Stephen’s Hospital challenging a district forum’s order directing it to pay Rs 1 lakh to Zafar, whose mother, Hazara Zafar Begum, had died there on March 8, 2000.
On January 15, 2000, she had complained of severe headache and was rushed to the hospital. Hazara was suspected to be suffering from migraine, but an MRI did not reveal any abnormality. A few days later, during her hospitalisation, she complained of severe abdominal pain. Doctors made a tentative diagnosis of cholecystitis (gall bladder inflammation), but an ultrasound test revealed biliary sludge and a stone in the common bile duct. An gastroenterologist advised endoscopic retrograde cholangiopancreatography (ERCP).
The procedure was performed on January 24, 2000 but the woman developed acute pancreatitis with formation of pus in her stomach and her condition deteriorated. Though she was moved to ICU on January 27, she didn’t survive.
Zafar alleged that his mother had succumbed to the excess use of laser beams. Contesting the allegation, the hospital said pancreatitis was a known complication of ERCP and was not a result of use of laser. “Non-performance of ERCP would have been an act of negligence,” it submitted.
The dean of Maulana Azad Medical College, who was called by the commission as an expert, said “there was no negligence on the part of the treating doctors in the management of post-ERCP pancreatitis”. However, he also pointed out that the decision to conduct ERCP was not very “robust”. As the ultrasound report was not definitive for the presence of common bile duct stones, MRCP should have been performed before doing ERCP, he added. “Had this been done, this ERCP and its subsequent complications could have been avoided,” the expert opined.