A Consumer Commission in Himachal Pradesh has mandated a financial compensation exceeding Rs 10.25 lakh to the family of a woman who passed away reportedly due to complications arising from a blood transfusion during her knee replacement surgery at a private nursing home. The commission found the medical establishment culpable of negligence, highlighting that the blood unit was stored improperly for over 22 hours without adherence to necessary protocols.
The commission, led by President Hemanshu Mishra alongside members Arti Sood and Narayan Thakur, acted on a grievance originally lodged by the deceased woman’s husband. Following his demise during the proceedings, his legal representatives continued to pursue the case.
On August 25, the court stated, “We do not find any error, much less a material irregularity or illegality, to justify the exercise of revisional jurisdiction conferred on this Commission… Therefore, we see no reason to interfere with the contested orders and the concurrent findings.”
The woman was admitted to the nursing home on March 22, 2023, for a total left knee replacement. Upon admission, her vital signs were stable, and there was no documented history of diabetes or hypertension. The surgical procedure took place the following day, on March 23, 2023.
Prior to the operation, the nursing home requested that the family arrange for a unit of blood for potential emergency use. On March 23, the family obtained a packed red blood cell unit from a blood center and delivered it to the nursing home that same day.
Documentation from the blood center indicated that the unit had undergone compatibility testing and was deemed suitable for the patient. It was issued at 1:54 PM on March 23 and was transfused roughly 22 hours later, on March 24, according to the commission’s findings.
The commission pointed out that the blood center specified a storage temperature of 2 to 6 degrees Celsius in a dedicated refrigerator and that transfusion should be completed within four hours of issuance. It further referenced transfusion guidelines that necessitate appropriate storage and timely administration of red blood cells.
The nursing home contested claims of negligence, asserting that the transfusion was essential due to blood loss during surgery and that the procedure was halted when the patient exhibited symptoms such as chills and shivering. They also mentioned other medical complications that could have contributed to her condition.
However, the commission concluded that the nursing home failed to demonstrate adequate storage of the blood unit. It noted that the refrigerator’s temperature monitor seemed to be nonfunctional, and the temperature chart was unreadable.
Additionally, discrepancies were found in the transfusion records; for instance, the flow sheet indicated transfusion occurred from 12:45 PM to 12:55 PM, while the adverse reaction report documented a time frame from 11:00 AM to 1:10 PM. Differences were also noted in the recorded respiratory rate and oxygen saturation levels. The commission criticized the discharge summary for neglecting to include details about the transfusion and the adverse reaction, branding it as incomplete and inadequate.
The woman was transferred to Dr. Rajendra Prasad Government Medical College (RPGMC) in Tanda on March 25, 2023, after her condition worsened. She developed severe complications including sepsis, multiple organ dysfunction syndrome, septic shock, and acute kidney injury, with a suspected transfusion-related acute lung injury, ultimately leading to her death on March 28.
According to Dr. Sujeet Raina, a medicine professor at RPGMC, the primary cause of death was attributed to severe sepsis, multiple organ dysfunction syndrome, septic shock, and suspected transfusion-related acute lung injury, which culminated in cardiopulmonary arrest.
The commission found the nursing home liable for negligence due to its failure to follow established protocols and its record-keeping inconsistencies. No negligence was attributed to the blood center, RPGMC, or the health department.
The commission instructed the nursing home to compensate the complainants with Rs 10 lakh and to cover Rs 25,000 in litigation expenses. A punitive fine of Rs 50,000 was also imposed, to be contributed to the District Consumer Legal Aid Fund in Kangra.
Moreover, the commission clarified that the insurers were not necessary or proper parties in this consumer complaint. However, it allowed the nursing home to seek indemnification under its insurance policy, directing the insurer to process and settle the claim within 30 days of receipt.
This case underscores the critical nature of proper blood storage, timely transfusion, and accurate medical record-keeping. The commission emphasized that healthcare facilities must adhere strictly to transfusion protocols and maintain clear and consistent documentation, particularly in instances of adverse reactions.
Consumers seeking assistance can reach out to their respective state consumer helplines (Himachal Pradesh: 1800-180-8087) or contact the National Consumer Helpline at 1915.
