Minor treated for “Measles” instead of “Stevens-Johnson Syndrome” due to wrong diagnosis and leading to medical negligence: Read detailed report on NCDRC’s decision

National Consumer Disputes Redressal Commission (NCDRC): While noting a case of medical negligence, the Coram of Justice R.K. Agrawal (President) and Dr S.M. Kantikar (Member) found that the doctor failed to correctly diagnose a serious disease of the minor which led to a lack of skill and reasonable standard of care.

Medical Negligence

A minor filed a Consumer Complaint before the District Consumer Disputes Redressal Commission Forum through her father alleging medical negligence against the OPs/Petitioners for wrong diagnosis and wrong treatment which led to rashes on her body and became beyond control. It was further alleged that OP 2 being a BAMS (Ayurveda Doctor) was not competent to prescribe allopathic medicines, which amounted to medical negligence.

District Forum had directed a compensation of Rs 1 lakh along with interest @9% to the complainant. When the matter reached the State Commission, it was held that the petitioner was entitled to prescribe and treat the patient with Allopathic Medicines but held the petitioner liable for medical negligence for the wrong diagnosis ad treatment.

OPs being aggrieved with the above order filed present revision petition.

Analysis, Discussion and Decision

From the medical record, it was apparent that the Petitioner was qualified, in the system of Ayurveda medicine, as a BAMS.

On 03-03-2009, he recorded the clinical findings as “fever (1020F), Bilateral Conjunctivitis +ve, Stomatitis +ve and made the diagnosis as ? measles. He prescribed medicines the antibiotic (Acef 100mg), Boroglycerine, steroid – tablet Dexa 1 tid, and eye drop. On the next day, patient had more itching, therefore he stopped oral Dexa and gave injection Efcorline (Hydrocortisone) and thereafter, the patient was referred to the physician, Dr R.S. Rai, who suspected it as ‘Stevens Johnson Syndrome’ (for short ‘SJ syndrome’) and further referred to Rajindra Hospital at Patiala.

According to the Petitioner, the same treatment which he gave in his hospital was given at the Rajindra Hospital. Though, he was BAMS, but he was allowed to practice and prescribe allopathy treatment as per the notification dated 18-06-2004 issued by the State Government of Punjab. Therefore, there was no fault or negligence in his treatment.

Cross Pathy

Commission noted that as per the Supreme Court decision in Dr Mukhtiar Chand v. State of Punjab, (1998) 7 SCC 579Ayurveda, Siddha, Unani and Homeopathy practitioners can prescribe allopathic medicines only in those states where they are authorized to do so by a general or special order made by the State Government concerned.

Further, the Coram expressed that, Few State Governments have authorized AYUSH doctor(s) it by some special order(s) to prescribe medicines of allopath, but in our view, that does not authorize the doctor to deviate from the standard of care which results into wrong diagnosis and prescribe wrong medicines.

 In the instant matter, the petitioner failed to diagnose the serious disease correctly as SJ syndrome, but he continued to treat the patient for measles and further failed to administer proper doses of steroids. Such act of the petitioner amounted to lack of skill and reasonable standard of care.

Coram relied on the Supreme Court’s decision in Poonam Verma v. Ashwin Patel, (1996) 4 SCC 332, wherein it was held that “the doctor must not only be qualified, but he must also be registered with the appropriate Medical Council in order to practice as a doctor. A homoeopath would not have knowledge about allopathic medicines and its drug actions, so administration of allopathic treatment by a homoeopath would be proof enough to establish negligence”.

Commission on perusal of the treatment record of Rajindra Hospital, Patiala noted the serious condition of the patient due to SJ syndrome.

Coram noted the 4 points on which the OP 2 failed:

  • Failure to correctly diagnose the condition as SJ syndrome but treated the patient for Measles.
  • The dose of steroid 4mg Dexa was inadequate for the patient; the dosage should be calculated as per kg of body weight.
  • For treatment of SJ syndrome the appropriate drugs of choice would be Cyclosporine with Methylprednisolone and the dosage to be per kg body weight of the patient.
  • There was a delay and wrong referral of the patient to the physician instead of a skin specialist.

Noting that the medical negligence occurred in 2009 and now we are in 2022, the compensation awarded was certainly on the lesser side.

The patient at her young age of 12 years suffered very serious and potentially fatal SJ syndrome. It was the patient’s sheer good luck that she survived in spite of such grossly inappropriate/inadequate treatment at every stage.

 Therefore, the patient deserved enhanced just and reasonable compensation.

Commission awarded a lump sum amount of Rs 10 lakhs as just and reasonable while disposing of the revision petition. [Chandigarh Nursing Home v. Sukhdeep Kaur, 2022 SCC OnLine NCDRC 5, decided on 3-1-2022]


Advocates before the Commission:

For the petitioner: K.G. Sharma, Advocate

For the respondent: Amn Priye Jain, Advocate

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