Morning MEDtalks with Dr K K Aggarwal 17^th July 2018

Baby dies in mothers womb

The family members of a pregnant woman staged a protest demonstration at Murshidabad Medical College and Hospital on Saturday night alleging that their baby died in her womb due to medical negligence of the doctors.

The family members of the woman alleged that during the examination, the nursing staff members told the patient that the baby was moving inside the womb. But later, the family members of the patient were told that the baby had died inside the mothers womb.  

MEDtalks: Foetal death

The stillbirth rate is approximately 6.2/1000 live births and fetal deaths. Stillbirth is the end result of many maternal, fetal, and placental disorders. However, many remain unexplained. Risk factors for stillbirth include black race, older maternal age, obesity, multiple gestation, concurrent medical disorders, smoking, and pregnancy complications.

Twenty-five to 60 percent of stillbirth is unexplained, especially late in gestation. No intervention has been proven to significantly reduce the rate of stillbirth in the general obstetrical population. Interventions such as achieving good glycemic control, induction of labor, Doppler velocimetry, and early induction of labor are useful in selected high-risk populations. 

A full autopsy without restrictions and including placental pathologic examination is optimal for determining the cause of death

The diagnosis of fetal death is based on an ultrasound examination that documents absence of fetal cardiac activity. Once fetal demise has been confirmed by ultrasound, the mother/couple should be informed in person, expeditiously, in an empathetic and straightforward manner, in surroundings where she/they can react privately.

Beginning at the time of diagnosis, women/couples who lose a baby may experience the five stages of grief experienced by individuals when told that they have a terminal illness (denial, anger, bargaining, depression, acceptance).

One can follow six-step protocol (SPIKES) for delivering bad news. setting up the interview with the patient and others she chooses to include, assessing the patient’s perception of the situation, understanding the amount of information that the patient wants to receive, providing this information, addressing the patient’s emotions with empathetic responses, and lastly summarizing and developing a plan.

Woman dies during surgery, family alleges negligence

A 50-year-old woman died during a kidney operation at a private hospital in Patiala here on Sunday morning. Members of the deceased’s family have alleged negligence. However, doctors said the patient had died due to the cardiac arrest.

The deceased, Shanti Devi, was admitted to Janak Surgicare and Ankur Advanced Urology Centre for bilateral kidney ailment on July 12. Shanti Devi, a resident of Ulaana village near Ghanaur in Patiala, was earlier operated for kidney stone on July 13 and July 14. However, she died during another operation on Sunday morning, said the police.

Doctor Ankur Bansal from the hospital said: “The patient was suffering from bilateral kidney ailment. She was operated on July 13 and July 14. However, when we were operating for the third time on Sunday morning, the patient died during operation due to a cardiac arrest after anaesthesia. ( TOI, Tribune)

Anaesthesia deaths: Overall anesthesia-related mortality rates vary from two deaths per 10,000 anesthetics to one death per 200,000 anesthetics. Standard American Society of Anesthesiologists (ASA) monitors include pulse oximetry, electrocardiography (ECG), a noninvasive blood pressure device, and temperature, as well as integrated monitors on all anesthesia machines that generate alarms for common and/or serious potential problems.

Risk of surgery

No surgery is risk free.

Low-risk patients — Patients whose estimated risk of death is less than 1 percent are labeled as being low risk and require no additional cardiovascular testing.

Higher-risk patients — Patients whose risk of death is 1 percent or higher may require additional cardiovascular evaluation. 

Ants in the wound

In an alleged case of medical negligence, a middle-aged unidentified man died at a state-run hospital in Chhattisgarhs Koriya district in lack of medical treatment, as ants fed off his wounds and bed sores for days, NDTV reported. 

MEDtalks: What attracts the ants and flies in the wound

1.  Dirty infected wound attracts ants and maggots. They bare natural scavengers.
2. Unhygienic status of the wound surroundings
3. In the US maggots are available in the chemist shops for use in selective cases.

Biologic — An additional method of wound debridement uses the larvae of the Australian sheep blow fly or green bottle fly, Medical Maggots, Monarch Labs, Irvine, CA) [38,39]. Maggot therapy can be used as a bridge between debridement procedures, or for debridement of chronic wounds when surgical debridement is not available or cannot be performed.  Maggot therapy may also reduce the duration of antibiotic therapy in some patients.

The larvae secrete proteolytic enzymes that liquefy necrotic tissue which is subsequently ingested while leaving healthy tissue intact. Basic and clinical research suggests that maggot therapy has additional benefits, including antimicrobial action and stimulation of wound healing.

How quantum of compensation is decided by district consumer courts: Death of 15 years old son with proven medical deficiency

“36) In this case in our hand the son of the present complainant’s wife of Badri Chowdhuri,

Dinanath Chowdhuri at the age of 15 years. The death of the son causes immense sufferings of the  family. That son after having maturity might have do some work and earn some money for the help of the family. But death of unfortunate boy has immerged the family in the world of uncertainty.

37) Complainant stated that her son used to earn Rs. 2500-4000 per month and used to contribute his entire earning for day to day necessities of the complainant’s family.

In this point Ops have no saying. At present, in an unfortunate death of anyone, or by accident, the average income is Rs. 72,000/-. At present the average life expectancy is 70 years. So, the working period stands as 70 – 16 = 54 years. The boy is now dead. So, his earning stands Rs. 72,000 – 24,000 = Rs. 48,000/- as one third presumed to be used by the deceased for his own and Rs. 48,000/- would have been used for the family. So, the total loss is Rs. 48,000 * 54 years = Rs. 25,92,000/-. But this Forum has power to award maximum award of Rs. 20,00,000/-.

38) Leaving apart the above income the mother and brother of the deceased are being deprived of loving touch of deceased. The loss of a child to a mother cannot be compensated by money. Son or daughter whatsoever may be is a very essential place of peace of a woman or a man. In no way the sufferings and vacuum created by the death of Dinanath Chowdhury can be filled up including the empty heart of the mother.

39) So, after deep contemplation over the principle of law and reason explained in different cases decided by the Hon’ble National Commission and Hon’ble Supreme Court we are of opinion that  Rs. 19,20,000/- if given as compensation for the death of Dinanath Chowdhury to the family of Dinanath Chowdhury then complainant’s loss will be satiated, at least, financial side and the soul of deceased shall be in peace who died for want of proper treatment.”

DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, HOOGHLY, CC OF 2013, Complaint Case No. CC/59/1996, ( Date of Filing : 09 Nov 1996 )

Max Shalimar Case Judgment: DMC/DC/F.14/Comp. 2269/2018/ 2^nd May, 2018

The Delhi Medical Council through its Disciplinary Committee examined a suo motu notice of media reports as per which a newborn baby was declared dead alongwith his still borne twin and handed over to his parents at Max Hospital, Shalimar Bagh, New Delhi. The Order of the Disciplinary Committee dated 19^th March, 2018 is reproduced herein-below:-

The Disciplinary Committee of the Delhi Medical Council examined a suo motu notice of media reports as per which a new born baby was declared dead along with his still borne twin and handed over to his parents at Max Hospital, Shalimar Bagh, New Delhi.

It is noted that the Delhi Medical Council has also received a representation from the Office of the Commissioner of Police: Delhi, Directorate General of Health Services, Govt. of NCT of Delhi and the Medical Council of India whose subject matter is same as that of aforesaid suo motu notice of media reports, hence, the Disciplinary Committee is disposing both of these matters by this common Order.

The Disciplinary Committee perused the media report, copy of representation from Police, written statement of Dr. Uma Rani Swain, Dr. Ajay Prakash Mehta, Dr. Vishnu Dutta Agarwal, Dr. Leena Bhatnagar, Dr.  Latika Singh Sinsinwar, Dr. Nitin Gupta, Dr. Gaurav Mandhan, Dr. Shweta Tahlan, Dr. Vishal Gupta, Ms.  Priyanka Sharma, Ms. Sreelatha KC, Dr. Archana Bajaj, Medical Superintendent of Max Super Specialty Hospital, copy of medical records of Max Super Specialty Hospital and other documents on record.

The following were heard in person:

1. Smt. Varsha           Complainant
2. Shri Satish Kumar Grand Father
3. Shri Kailash Father-in-law of the complainant
4. Shri Abhishek        Brother
5. Shri Ashish Husband of the complainant
6. Dr. Uma Rani Swain         Sr. Consultant, Obst. & Gynae. Max
7. Dr. Ajay Prakash Mehta    Sr. Consultant, Paediatrics, Max
8. Dr. Vishal Gupta         Attending Consultant, Max Hospital
9. Dr. Gaurav Mandhan, Attending Consultant, Neonatology, Max
10. Dr. Leena Bhatnagar, Associate Consultant, Obst. & Gynae, Max
11. Dr. Latika Singh Sinsinwar, SR, Obst. & Gynae., Max Hospital
12. Dr. Vishnu Dutta Agarwal, Consultant, Paediatrics, Max Hospital
13. Dr. Nitin Gupta, Attending Consultant, Paediatrics, Max     
14. Dr. Shweta Tahlan:     Attending Consultant, Obst. & Gyane., Max
15. Ms. Sreelatha K Staff Nurse, Max Hospital
16. Ms. Priyanka Sharma Staff Nurse, Max Hospital
17. Shri Kuldeep Sharma VP, Max Hospital
18. Dr. Archana Bajaj       Medical Superintendent, Max Hospital

Shri Kailash father-in-law of the complainant stated that the complainant Smt. Varsha was six months’ pregnant and due to problem in stomach, on 27^th November, 2017, she was admitted in Atam Nursing Home, Paschim Vihar, Delhi and on 28^th November, 2017, she was referred to Max Hospital, Shalimar Bagh, Delhi.  At time of admission in Max Hospital, the doctors told that she is having twins and possibility of their survival is 10% to 15%.  Further, the doctor directed them to bring three injections and the same were purchased for Rs.35,000/- and the treatment was started.   The said injections were provided by one of the hospital staff.  On 29^th November, 2017, the doctors stated that now survival of twins is 30%.  On the same day at 8.00 p.m. the doctors informed that she has started bleeding and has to be operated upon.  On 30^th November, 2017 at 7.30 p.m., the delivery of first baby (male) was done who was having heartbeat and at about 7.42 a.m., the second baby (female) was born with the report as dead.  The doctors told that alive baby will be kept in nursery and the charges would be to the tune of Rs.50 lacs.  At 1.00 p.m., they were informed by the doctor that the male baby is also dead.  Both the dead babies were handed over to the family members in two different parcels in a yellow coloured poly-bag by hospital staff for cremation.  While on way to cremation centre alongwith babies, at Madhuban Chowk, he felt some activity in the body of the male baby.  On this, the parcel was opened and it was found that the male baby was alive.  They rushed to nearby Agarwal Hospital, Pitampura, Delhi where male baby was got admitted and subsequently died.  Female baby was cremated at Chander Vihar.  He further stated that the doctors of Max Hospital have been negligent in declaring a live baby as dead and legal action may be taken against them accordingly. 

On enquiry by the Disciplinary Committee, he further stated that between 7.30 a.m. to 12.30 a.m. (30-11-2017), no treatment was given to the male baby by the doctors of Max Hospital.  He also stated that both the dead and live babies were kept together in a warmer.  He further stated that the expenses for the treatment under of babies were informed before the delivery. 

Dr. Latika Singh Sinsinwar, SR, Gynaecology in her written statement averred that at 7.15 a.m. while performing reassessment P/V examination of the patient Smt. Varsha, the first twin with sac was bulging.   She informed this to Dr. Uma Rani Swain and Dr. Uma Rani Swain advised her to wait for expulsion of the baby.  So she shifted the patient to labour table and informed her associate consultant Dr. Leena Bhatnagar about the expulsion and asked her (Dr. Leena Bhatnagar) to come.  At 7.30 a.m., the first twin expelled by footling, paediatrician doctor came when she was cutting the cord; she handed over the baby immediately to the paediatrician doctor.  At 7.42 a.m, the second twin was delivered by vertex, and handed over to paediatrician doctor.  The placenta was not separating and she was not able to deliver out the placenta, this was informed to Dr. Leena Bhatnagar and Dr. Uma Rani Swain over phone.  At 7.45 a.m., Dr. Leena Bhatnagar arrived, got washed with her and both of them tried to remove placenta.  At 9.00 a.m., she handed over the labour room to Dr. Shweta Tahlan who came for labour room duty on that shift.  None of the baby cried after birth, however, she observed that first baby had occasional gasping respiration.  She did not observe the same in second twin.  All the findings were informed to Dr. Uma Rani Swain all throughout over phone. 

Dr. Nitin Gupta, Paediatrician who was present at the time of delivery in his written statement averred that he was on night duty on 29^th November, 2017 till 30^th November, 2017 till 9.00 a.m.  Around 7.30 a.m. he received information from Dr. Vishnu Dutta Agarwal that a 22+5 weeks delivery case is there in labour room.  He reached there with Dr. Vishnu Dutta Agarwal.  The first baby was expelling and he received the baby.  In the meantime, Dr. Vishnu Dutta Agarwal discussed with attendants regarding resuscitation but they refused and he put the baby under warmer, after initial steps.  Then, he informed his senior consultant Dr. Ajay Prakash Mehta regarding the same and he (Dr. Ajay Prakash Mehta) replied that if they are refusing for resuscitation, then do not do and put under warmer only.  One day before, they were counselled by Dr. Ajay Prakash Mehta and they were of same opinion.  Later, the second baby was delivered that was still born.  The same was again informed to Dr. Ajay Prakash Mehta and was also informed to the attendants, but they again refused for resuscitation.  The same has been mentioned in notes written in maternal file as well as consent was taken from the attendants regarding not to resuscitate. 

On enquiry by the Disciplinary Committee, he further stated that negative consent for resuscitation was written by him, however, he had not put his signatures.  The attendants signed in his presence.  He also stated that he wrote the notes of still born baby. 

Dr. Ajay Prakash Mehta (Dr. A.P. Mehta), senior consultant, Neonatology in his written statement averred that the patient Varsha, 20 years, female with 22-23 weeks of pregnancy was admitted with leaking membranes and pain abdomen on 28.11.17. There was history of similar complaints 3 weeks earlier also, for which she was admitted in some nursing home. Her counts were raised and CRP was positive. He counseled the grandparents about the possible outcome if the delivery happened to take place now. They asked him about chances of survival, the likely duration of hospitalization, the cost of such hospitalization and chances of survival without physical and mental deficiency.  He informed them that as per medical norms the chances of survival are very low and if the child survives the chances of intact survival that is without a physical or developmental problem are also equally very low. He further informed them about the prolonged stay in NICU including ventilator support and discussed the likely cost of hospitalization i.e. initially Rs. 20,000 to 25,000 per day and as the level of care decreases charges will also decrease. The relatives then asked him can he guarantee the child will be normal if survived.  He categorically informed them it is impossible for him to give any guarantee of a normal child after survival. At this time, the relatives clearly instructed him that if the patient delivers now, they will not like him to do any resuscitation or intervention for the new-borns.  Next day in the morning at 7.30 a.m., the patient delivered 22-23 weeks premature twins - twin one male and twin two a stillborn female. The doctors attending the delivery informed him that they counselled the relatives about resuscitation, which was refused by them. The father and grandfather duly signed the Do No Resuscitate (DNR) after fully understanding the situation and its implication.  Twin one was kept under warmer after initial steps of resuscitation and was continued with comfort care.  He reviewed the baby-twin one with his associate consultants Dr. Vishal Gupta (MD, DNB Neonatology) and Dr. Gaurav Mandhan (MD, Fellowship Neonatology), both qualified neonatologists at 10.00 a.m. and told the father that the baby had feeble heart beats. The father again said that they do not want any active treatment or intervention. After this interaction and discussion with father, he did not see or clinically examine the baby.  He was informed at about 12.30-12.40 p.m. by Dr. Vishal Gupta that he had examined the twin one and did not find any heart sounds. By the time, he could have gone and seen the twin, the baby had already been handed over by the nursing staff to the relatives. He did not declare the baby dead. In fact, the twins were handed over without his knowledge and approval.  It is pertinent to mention here that neither he examined the baby after 10.00 a.m. nor he declared the twin one dead.  There are strong recommendations not to resuscitate babies below 25 weeks.  He has followed standard teaching and practice guidelines while advising parents and relatives of baby of the patient.  He has always performed and discharged professional duties diligently, carefully, honestly and to best of his ability and knowledge as per settled/prescribed medical standard of care.  He has been truly ethical and followed Hippocratic Oath. 

On enquiry by the Disciplinary Committee, he further stated that ante-natal counselling was done by him even though, it had not been countersigned by the patient / attendants.  He also stated that between 10.00 a.m. and 10.30 a.m., he saw the patient with Dr. Vishal Gupta.  He briefed about the condition to the father of the babies, Shri Ashish. 

Shri Ashish stated that at around 10.30 a.m., he was informed that both babies were dead. 

Dr. Vishnu Dutta Agrawal, Consultant Paediatrics in his written statement averred that on 30^th November 2017 approximately at 7.29 - 7.30 a.m. in morning, he received a call from labour room gynae. senior resident that a twin pregnancy mother is going to expel, mother is 22 weeks for abortion.  He informed Dr. Nitin Gupta (Neonatal fellow) and along with him reached LR within a minute at around 7.30 a.m.  Dr. Nitin Gupta received the baby and started providing comfort care to the baby.  The baby was having cardiac activity and gasps.  He went outside LR to talk to attendants.  As the baby was 22 +-5 week, he discussed with the parents, explained about the admission and active intervention.  Conveyed the same to Dr. Nitin Gupta and asked him to talk to Dr. Ajay Prakash Mehta about DNR protocol and the attendants’ choice.  Left the LR after handing over to Dr. Nitin at around 7.45 a.m.  The second twin who was delivered at 7.42 a.m. was a female baby, stillborn with no signs of life. 

On enquiry by the Disciplinary Committee, he further stated that he did post-delivery counselling but did not remember the person with whom he spoke. 

Dr. Uma Rani Swain, Consultant, Obst. & Gynae in her written statement averred that the patient Smt. Varsha, 20 yrs was received in emergency to labour room, Max hospital at 2.59 p.m. on 28.11.2017, referred from Attam IVF centre, Paschim Vihar, New Delhi as a case of Primigravida, IVF conceived, twins’ gestation at 23 weeks of pregnancy with H/O pain abdomen, leaking, bleeding for two days.  The patient has past history of triplet conception in current IVF procedure, embryo reduction, and cervical circlage at 14 weeks of gestation, hospitalized 3 weeks back for leaking bleeding and pain abdomen.  The patient was admitted in Attam Hospital on 27^th (one day before referral) with the same complains.  The findings at the time of admission were vitals stable, P/A- uterus 28weeks with intermittent contraction 20-30sec/ 1-2/10min, non-tender, P/S: excessive show with fluid, gentle P/V: upper 1/2 of Cx funnelling, length lcm along with circlage, leaking + treatment.  Immediate Treatment after Admission on 28.11.2017; 2.59 p.m. IV fluid, triple antibiotics, Tab Nifedipine, sedation, steroid, Proluton depo and other symptomatic treatments 28.11.2017 at 6.00 p.m., the patient’s conditions remained the same. TLC raised 13000, CRP 5.4.  Plan for oxytocin receptor inhibitor atosiban was planned in view of previous treatments during hospitalization and current condition of patient.  The patient attendants were counselee regarding the condition of the patient and the effects of the drugs to arrest the progress was only 10%. They agreed to our treatment plan and procured the medicine for immediate use (3 vails) as the said drug was not available then in hospital pharmacy. Subsequently hospital arranged for its further use. On 28.11.2017 at 10.30 p.m., bleeding and leaking reduced. Pad was superficially soaked.  On 29.11.2017 at 7.15 a.m., uterus 28 weeks, symptoms reduced, contraction mild, no leaking with passage of clot P/V.  On 29.11.2017 at 10.00 a.m., USG done, features of cervical funnelling and oligohydramnios of second twins were reported.  TLC increased to 19000 for which antibiotics was upgraded to tazobactam. All other treatments were continued.  The patient’s attendants were informed and counselled regarding the patient’s conditions and the treatments.  On 29.11.2017 at 9.00 p.m. the patient started showing uterine contractions, leaking and bleeding with clots for which with full information to the patient’s attendant, previous treatment was stopped and circlage was removed in labour room.  P/V: Cx 1.scm, Cxfull of clots, footling felt in upper part of Cx.  On 29.11.2017 at 7.30 a.m., expulsion note: spontaneous expulsion - 1^st at 7.30 a.m., male and 2^nd at 7.42 a.m. female.  Both twins were handed over to paediatricians immediately after delivery.  Placenta were adherent to ut all and expelled spontaneously after 45 minutes.  Few bits left inside the cavity. No intrauterine manipulation or intervention was done in view of chorioamnionitis.  On 29.11.2017 at 10.25 a.m., following complete assessment of the patient, the patient was planned for discharge with IV antibiotics. After thorough discussions with attendants regarding future follow ups, medications and planning for pregnancy, she was discharged at 12.30 p.m.  Thus, it may kindly be observed from the history of the patient and her condition at the time of admission that the patient was attended and extended all possible medical treatment immediately for her well-being and all her attendants present in the hospital were informed/ counselled, at each stage from time to time, with regard to patients condition, line of treatment. Treatments were undertaken at each stage after informing the attendants and with their consent only. At no point of time, neither the patient, nor their attendants had complained about the treatment by the attending obstetrician team of the hospital. As evident from the aforesaid facts, it may kindly be observed that there is no medical negligence, as alleged, on our part (obstetrician unit) with regard to treatment of the patient (mother) and her well-being.  As regards the allegation that a new born baby (23-week foetus) was declared dead along with his stillborn twin and was handed over to the parents, she would like to submit that both the twins were handed over to paediatrics team of the hospital immediately after their delivery as per medical protocol. Therefore, they the obstetricians in the case are not appropriate authority to comment on the same. All the relevant documents in support of the facts explained herein above are available in hospital record.

On enquiry by the Disciplinary Committee about the protocol for still birth, she further stated that obst. & gynae team declares still birth.  She informed about still birth to father-in-law of the complainant. 

Shri Kailash, Father-in-law of the complainant admitted that he was informed about the still birth. 

On further enquiry by the Disciplinary Committee, Dr. Uma Rani Swain further stated that they generally hand over to sister the still birth, which unfortunately was not done in this case. 

Ms. Priyanka Sharma, Staff Nurse in her written statement averred that as advised/instructed by Dr. Vishal Gupta, she informed sister Shreelatha to handover the babies to the relatives/attendants.  The twins were delivered at 23 weeks of pregnancy.  The twin two was still born and twin one was born with severe bradycardia with heartbeat around 30 per minutes only.  Thus, twin one had extremely poor chance of survival, since, as per international medical literature, foetus less than 24 weeks, if born, is an abortus and is not considered-viable and is not likely to survive.  The Delhi Registration of Birth and Death Rules, 1999 prescribe that 28 weeks is period of gestation for it to be viable.  Moreover, giving due respect to the decision of the family of the patient and in view of the DNR instruction given by Shri Ashish (Father) and Shri Vipin Malik (Attendant); the treating team did not attempt any resuscitation measures after initial steps, in accordance with the available medical protocols.  It is also wrong, and she strongly denies the allegation that twins were handed over to the relatives wrapped in polythene bag.  The twins with no sign of life were handed over to the relatives/attendant of the patient covered in clean white sheets, by sister Shreelatha/herself, in the presence of the security team and obst. & gynae. doctor.  To her understanding, the patient’s family on its own, for the ease of carrying, requested for and put the babies in the non-chlorinated yellow bag kept in the labour room, which was neither permitted nor sealed/packed by the doctors or staff of the hospital. 

On enquiry by the Disciplinary Committee, she further stated that she was not given instruction about still birth.  Both twins were kept in warmer; live and still birth.  She also stated that Dr. Vishal Gupta checked the heart beat and said there was no heartbeat.  He asked her to hand over the babies to the attendants.  The instructions were not documented. 

On further enquiry by the Disciplinary Committee, Ms. Priyanka stated that no death certificate was made because the male baby was not admitted. 

Dr. Archana Bajaj, Medical Superintendent stated that the baby’s death was not notified because in records the baby was not admitted. 

Dr. Vishal Gupta, Attending Consultant Paediatrics in his written statement averred that the patient Smt. Varsha got admitted on 28/11/17 under Dr. Uma Rani Swain and antenatal counselling was done by Dr A.P Mehta on 29/11117 regarding prognosis, treatment and finances. On 30^th November 2017, expulsion of two twins happened - twin 1 (Male) at 7:30 AM and Twin 2 (Female) at 7.42 AM.  None of the babies cried after birth. Twin 1 had severe bradycardia with heart rate around 30/minute (which in normal cases usually ranges from 120 to 180 per minute). Twin 2 was still born. It may be noted that this was inevitable abortion by way preterm premature rupture of membranes ("PPROM") as the pregnancy was only 23 completed weeks from LMP.  The patients family was called post expulsion of the twins. The patients family was explained about the present conditions of the twins, prognosis, treatment protocol, possible outcome (viz. long term neurodevelopment disorders, disability etc) and counselled by Dr. Vishnu Dutta Aggarwal and Dr Nitin Gupta in full detail and after having fully understood, after the counselling the family refused for any kind of resuscitation of the twins and issued instruction for Do No resuscitate (DNR), confirming that neither the hospital nor the doctors involved would be liable for the decision taken by the family, however, as respondent was not personally involved in the delivery or the treatment of the patient smt. Varsha, hence, could not affirm the said version of hospital.  At about 10.10 AM, he along with Dr. AP Mehta and Dr. Gaurav Mandhan went to the labour room to see the baby, at that time baby twin 1 had gasping breaths.  Subsequently Dr. A.P Mehta had asked him to see baby again at around 12.12 pm on 30^th November 2017, when the twin 1 was examined, the attending consultant (Paediatrics) i.e. he could not hear the heartbeat of twin 1(male).  He informed the sister that he could not hear heart beat and he will inform the same to Dr. A.P Mehta to check and thereafter, he left the labour room. He duly informed the said fact to senior paediatrician Dr. A.P. Mehta for further course, thereafter, he never got in touch with the said baby in any manner, and even otherwise, he was under no capacity or duty to look after in this regard in the present case, being only the attendant to Dr. A.P. Mehta, senior paediatrician /treating doctor.  He would like to draw the attention to the Delhi Medical Association Press release dated 7/12/2017 F75, DMA/2017, wherein the above-mentioned fact was endorsed and approved. Thereby stating "many times due to hypothermia the heart beat in such cases may be absent and reverts from time to time. Such rare cases have occurred in the past across many parts of the world including recent one in Safdarjung Hospital in June 2017.   He would also like to draw the attention to the findings of the Directorate General of Health Services (Govt. of NCT of Delhi) order dated 08112/2017 f.24INH/DHS/HQ/NW/2017-201234709, wherein committee formed by Directorate General of Health Services in its enquiry has not found any evidence that the he was involved in the alleged unfortunate incident in any manner.  Further, the fact that the acknowledgement letter of handing over of the twin body to their attendant issued by Max Hospital does not bear his signature, which bears signature of family members of the new born along with signature of senior resident of OBG and concern nursing staff, which further demonstrate the fact that he was not involved in the alleged unfortunate incident in any manner what so ever. It is pertinent to mention herein that the Directorate General of Health Services order dated 08112/2017 has specifically pointed out the fact that the Staff Nurses on duty handed over the bodies of the new-borns without any written direction from the paediatrician. 

On enquiry by the Disciplinary Committee, Dr. Vishal Gupta stated that they never declared the baby dead.  He saw the male baby at 12.12 a.m.  He could not hear the heartbeat.  He told Dr. A.P. Mehta about no heartbeat. 

Dr. A.P. Mehta stated that he asked Dr. Vishal Gupta to observe for some time. 

Dr.  Shweta Talhan, Attending Consultant in her written statement averred that she came to duty in labour room on 30^th November, 2017 at around 9.00 a.m.  She took over of all gynae./obst. patients present in labour room at that time.  The patient Smt. Varsha had already delivered by that time and shifted to bed.  She took over of the patient.  At that time, the babies were in the delivery room in the warmer.  She did not see the baies, as the paediatricians were already seeing the babies and then, she became busy in her obstetric work.  In afternoon, the staff nurse on duty, Sreelata told her that the paediatrician has examined the babies and has decided to hand over the babies to the relatives.  She gave her the document to sign, required for security purpose stating that these babies are being handed over to the concerned relatives.  She signed the document, as it is required for the security reasons. 

Ms. Sreelatha K.C, Staff Nurse in her written statement averred that as advised/instructed by Dr. Vishal Gupta, she informed sister Shreelatha to handover the babies to the relatives/attendants.  The twins were delivered at 23 weeks of pregnancy.  The twin two was still born and twin one was born with severe bradycardia with heartbeat around 30 per minutes only.  Thus, twin one had extremely poor chance of survival, since, as per international medical literature, foetus less than 24 weeks, if born, is an abortus and is not considered-viable and is not likely to survive.   The Delhi Registration of Birth and Death Rules, 1999 prescribe that 28 weeks is period of gestation for it to be viable.  Moreover, giving due respect to the decision of the family of the patient and in view of the DNR instruction given by Shri Ashish (Father) and Shri Vipin Malik (Attendant); the treating team did not attempt any resuscitation measures after initial steps, in accordance with the available medical protocols.  It is also wrong and she strongly denies the allegation that twins were handed over to the relatives wrapped in polythene bag.  The twins with no sign of life were handed over to the relatives/attendant of the patient covered in clean white sheets, by sister Shreelatha/herself, in the presence of the security team and obst. & gynae. doctor.  To her understanding, the patient’s family on its own, for the ease of carrying, requested for and put the babies in the non-chlorinated yellow bag kept in the labour room, which was neither permitted nor sealed/packed by the doctors or staff of the hospital. 

On enquiry by the Disciplinary Committee, Ms. Sreelatha K.C further stated that Ms. Priyanka told her that Dr. Vishal Gupta has instructed her to hand over the baby to the attendants.  The baby was in the warmer.  She checked his heart beat and found it to be cold and wrapped it. 

In view of the above, the Disciplinary Committee makes the following observations :-

1. It is observed that antenatal counseling was done by Dr. A.P. Mehta, which was confirmed by the attendants.  However, there is no documentation of the contents of the counseling. 
2. It is observed that Dr. Vishnu Dutta Aggarwal, Consultant Paediatrics was unable to identify the family member whom he had counseled about twin 1 male, who had severe bradycardia and there is no documentation of the same.
3. At between 10.00-11.00 a.m. on 31^st January, 2018, Dr. A.P. Mehta alongwith Dr. Vishal Gupta and Dr. Gaurav Mandhan visited labour room and detected occasional heart beats.  Thereafter, Dr. A.P. Mehta has stated that he once again spoke/counseled the father of the twins Shri Ashish.  There is no documentation of this conversation, but it is alleged that the same is available in hospital’s CCTV footage.  Thereafter, Dr. Gaurav Mandhan has documented the counseling which was signed by the father Shri Ashish (he certified his signature before the Disciplinary Committee) but claimed to be unaware of the contents.
4. Secondly, there is no signature of Dr. Gaurav Mandhan, on the document and also the witness, who signed i.e. Ms. Varsha’s brother, was not present during the counseling and was done later.  The same could not be confirmed from the witness, as he was unavailable during the hearing before the Disciplinary Committee.
5. At about 12-12.20 p.m., Dr. Vishal Gupta visited the labour room and failed to detect the heart beat of the twin 1 male baby.  He informed staff nurse Priynaka and then went to NICU and informed Dr. A.P. Mehta.  Dr. A.P. Mehta had advised observation for one more hour for twin 1 male baby before confirming the death.  However, one hour later, they found that the LR staff had handed over the bodies of the twins to the relatives.
6. Staff Nurse Ms. Priyanka informed that she completed the handing over formalities, as she had been instructed by Dr. Vishal Gupta (which the latter denies).  It appears that there was no formal declaration of death of the male twin 1.
7. The hospital did not issue a death certificate for male twin 1 who had some heart beat for about 4-5 hours, since the baby was not admitted in the hospital, as the family did not want to admit the baby in NICU for further management.
8. There has been procedural lapses and inadequate documentation which is probably due to absence of standard operating guidelines when managing such cases.
9. It is pertinent to mention that at gestational ages of <24 weeks, the existing guidelines do not generally recommend life sustaining interventions and it is advised that this decision is made after discussing the baby’s conditions with the family. In the present instant, the decision for management of the baby was as per the existing guidelines by the treating doctors.
10. In light of the observations made hereinabove, it is the decision of the Disciplinary Committee that no medical negligence can be attributed on the part of doctors of Max Super Specialty Hospital, in the treatment administered to the complainant’s new born baby at Max Super Specialty Hospital.

Matter stands disposed.

The Order of the Disciplinary Committee dated 19^th March, 2018 was taken up for confirmation before the Delhi Medical Council in its meeting held on 19^th April, 2018 wherein “whilst confirming the decision of the Disciplinary Committee, the Council directed a copy of the Disciplinary Committee Order be also sent to the Directorate General of Health Services, Govt. of India and the Directorate General of Health Services, Govt. of Delhi for framing the guidelines for management of such gestational age babies.   

This observation is to be incorporated in the final Order to be issued.  The Order of the Disciplinary Committee stands modified to this extent and the modified Order is confirmed. 

By the Order & in the name of Delhi Medical Council

(Dr. Girish Tyagi) Secretary

DMC/DC/F.14/Comp. 2269/2018/   

9^th May, 2018

Subject :    Delhi Medical Council Order in Complaint No. 2269 – “a suo motu notice of media reports as per which a newborn baby was declared dead alongwith his still borne twin and handed over to his parents at Max Hospital, Shalimar Bagh, New Delhi”.

In reference to the Delhi Medical Council Order No.DMC/DC/F.14/Comp. 2269/2018/271793 to 271801, 271803-271804, 271806 to 271813 dated 2^nd May in complaint No.2269–“a suo motu notice of media reports as per which a newborn baby was declared dead alongwith his still borne twin and handed over to his parents at Max Hospital, Shalimar Bagh, New Delhi”, it is observed that due to inadvertence in the observation no.3 mentioned at page no.15/18 of the aforesaid Order, it is mentioned “At between 10.00-11.00 a.m. on 31^st January, 2018”.  It is informed that the same be substituted and read as “At between 10.00-11.00 a.m. on 30^th November, 2017”.  The rest of the Order remains the same.  

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