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Wrong Blood Transfusion Resulting In Death, A Case Of Medical Negligence; NCDRC

Mehak Dhiman
6 Jun 2022 10:30 AM GMT
Wrong Blood Transfusion Resulting In Death, A Case Of Medical Negligence; NCDRC
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A bench comprising Justice R.K. Agrawal, President and Dr. S.M. Kantikar, Member, has observed that, 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.

The bench noted that, 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.

In this case, A. K. Nazeer and his wife Sajeena were undergoing infertility treatment at Samad Hospital, Thiruvananthapuram ('Opposite Party No. 1'). The abdominal Ultrasonography (USG) scan revealed fibroid uterus. Sajeena underwent laparoscopic surgery. Dr. Sathi M. Pillai ('Opposite Party No. 2) asked for blood transfusion. After blood transfusion, she immediately developed blood transfusion reactions and complications. It was happened due to mismatched blood by transfusion. Being aggrieved by the alleged negligence, during blood transfusion, the Complainants filed the Consumer Complaint before the State Commission, Kerala and prayed for compensation of Rs. 45 lakhs with interest and Rs. 4.5 lakh towards medical expenditure. The State Commission partly allowed the Complaint and directed the Opposite Parties Nos. 1 and 2 to pay a total compensation of Rs. 9,33,000/- to the Complainants.

The State Commission observed that:

"The Opposite Parties Nos. 1 and 2 have failed to follow the standard procedures after the transfusion reaction. The hospital failed to communicate the blood bank and not investigated the transfusion reaction by sending the remaining blood bag, patient's blood and urine samples. It is evident from the cross-examination of DW-2, that the transfusion reaction was developed and no immediate steps were taken by the Samad Hospital. The case sheet also lacks details of treatment."

Aggrieved by the decision of State Commission Kerala the appellants filed an appeal before the National Commission under Section 19 of the Consumer Protection Act, 1986.

Analysis:

The issues for consideration before the bench were:

Firstly, whether wrong blood was transfused, if yes- then whether hospital or the blood bank is liable? Secondly, whether it was a transfusion reaction or DIC?

While answering the first question the bench noted that, it was endorsed by Dr. Valentina, the probable cause for the transfusion reaction is mismatched blood transfusion. The patient continues to be oliguric. Consequently, the entry itself is sufficient to prove that mismatched blood was transfused to the patient.

The bench further noted that, moreover, it was the duty of hospital to prove the wrong blood was issued from the Blood Bank, but the Appellant failed to prove it. The finding of State Commission shows 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. Accordingly, possibility of error in identification of the blood bags or identifying the patients was more.

The bench stated 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, there is no record that when the blood was brought from the blood bank. Consequently, it is concluded that wrong blood was transfused to the patient and the hospital staff is liable for the negligence.

While answering the second question the bench observed that, the witness Dr. Valentina deposed that the transfusion blood of B +ve group whereas the patient was O +ve. If the transfusion reaction is suspected, the duty of treating doctor is to immediately send the blood sample from a limb of other side and along with the blood for cross-matching. The urine to be examined for haemoglobinuria. It was legal duty of the blood bank to keep the pilot samples of the blood bags till the expiry of the blood. There was no such evidence that blood and urine sample were collected.

The bench stated that, 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. Transfusion reactions and adverse events should be investigated by the clinical team and hospital transfusion team and reviewed by the hospital transfusion committee.

The bench relied upon the case of Postgraduate Institute of Medial Education and Research Chandigarh vs. Jaspal Singh & Others, wherein it was held that "mismatch in transfusion of blood resulting in death of the patient after 40 days, a case of medical negligence."

The bench stated that, wrong blood transfusion to Sajeena 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. The Opposite Party No. 1 and 2 are liable for deficiency in service and the medical negligence.

The bench opined that, the State Commission erred in quantifying the amount Rs. 9,33,000/- as a compensation, but the complainants deserve for enhanced compensation. The bench directed the Appellants to pay Rs. 20 lakhs as compensation and Rs. 1 lakh towards the cost of litigation within 6 weeks from order to the parents of deceased Sajeena.

Case Name: M/S. Samad Hospital v. S. Muhammed Basheer

Case No.: FIRST APPEAL NO. 172 OF 2012

Corum: Justice R.K. Agrawal, President and Dr. S.M. Kantikar, Member

Decided on: 25th May, 2022

Click Here To Read/Download Order

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