Case Law: Importance Of Keeping Medical Records

A hospital would be well-advised to diligently and thoroughly update and maintain treatment records, as this could be one of the strongest defence they can present when facing a case of medical negligence.

Krishna Devi was pregnant, due to deliver and hence was taken to Jain Hospital at 3 PM. The doctors at the hospital, without wasting any time, took her under their care and diagnosed that her condition was poor. She was anaemic and her hemoglobin level was only 6.5.

She delivered a baby boy at 3:30 PM but suffered postpartum haemorrhage (PPH). The doctors administered medicine and gave a massage, but the patient’s relatives could not bring the required blood on time. She was referred to another hospital, but unfortunately died upon reaching there.

The patient’s relatives believed it was negligence on part of Jain Hospital and hence approached State Consumer Disputes Redressal Commission, Rajasthan. It was alleged that the relatives were not asked to arrange for blood when the patient was admitted. It was further alleged that the patient was transferred to another hospital without proper equipment or nursing staff. Lastly, it was also alleged that the hospital failed to call a surgeon and an anaesthetist and these facts amount to negligence.

The Commission perused the meticulous treatment records and observed that the patient was brought to the hospital at 3 PM, the relatives were asked to bring the blood at 3:15 PM. It was further observed that the hospital repeatedly asked for blood at 3:45 PM and 3:55 PM, but there was a delay of two hours on their part in arranging the same.

The Commission observed that the hospital had no other option but to transfer to the patient, who was in a serious condition, to a higher centre and the patient was accompanied by nursing staff. The Commission also observed that the patient reached the higher centre at 6:10 PM but was declared dead.

Finally, the Commission observed that the doctor who was treating the patient at Jain Hospital was a M.S. in obstetrics and gynaecology and since the relatives had not arranged for blood, there was no question of surgery and hence, no need for a surgeon or anaesthetist. Jain Hospital was held not negligent, and all credit to its staff for recording complete treatment and progress details almost minute by minute.

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