“We do not find any error, much less a material irregularity or illegality, so as to warrant exercise of revisional jurisdiction conferred on this Commission…Accordingly, we see no reason to interfere with the impugned orders and the concurrent findings,” the court said on August 25.
The woman was admitted to the nursing home on March 22, 2023, for a left total knee replacement. The commission noted that her vitals were stable at admission and the records showed no prior history of diabetes or hypertension. The surgery was performed on March 23, 2023.
Blood unit retained for over 22 hours
Before surgery, the nursing home advised the family to arrange one unit of blood for emergency or transfusion purposes. The family procured a packed red blood cell unit from a blood centre on March 23, 2023, and handed it to the nursing home the same day.
The blood centre’s records showed that the unit had been compatibility-tested and was compatible with the patient’s sample. It was issued at 1:54 pm on March 23 and, according to the commission, was transfused approximately 22 hours later on March 24.
The commission noted that the blood centre had specified storage at 2 degree Celcius to 6 degrees Celsius in a dedicated blood-storage refrigerator and that transfusion should be completed within four hours after issue. It also referred to applicable transfusion guidance requiring appropriate storage and timely administration of red cells.
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The nursing home denied negligence, maintaining that the transfusion was medically necessary because of blood loss during surgery and that it was stopped when the woman developed symptoms including chills and shivering. It also cited other possible medical complications.
Commission flags storage and record lapses
The commission found that the nursing home failed to establish proper storage of the blood. It noted that the refrigerator’s temperature monitor appeared non-functional and the temperature chart was illegible.
It also flagged contradictions in transfusion records- the flow sheet recorded transfusion from 12:45 pm to 12:55 pm, while the adverse reaction form recorded 11 am to 1:10 pm. Respiratory rate and oxygen saturation records also differed. The commission further faulted the discharge summary for omitting the transfusion and adverse reaction, calling it deficient and incomplete.
The woman was referred to Dr Rajendra Prasad Government Medical College (RPGMC), Tanda, on March 25, 2023, after her condition deteriorated. She developed sepsis, multiple organ dysfunction syndrome, septic shock and acute kidney injury, with suspected transfusion-related acute lung injury, and died on March 28.
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Dr Sujeet Raina, professor of medicine at RPGMC, Tanda, said the root cause of death was severe sepsis, multiple organ dysfunction syndrome, septic shock and suspected transfusion-related acute lung injury, leading to cardiopulmonary arrest.
The commission held the nursing home liable for negligence over failure to follow standard procedures and discrepancies in its records. It found no negligence against the blood centre, RPGMC, Tanda, or the health department.
The commission directed the nursing home to pay Rs 10 lakh compensation to the complainants and Rs 25,000 towards litigation costs. It also imposed a punitive fine of Rs 50,000, to be deposited into the District Consumer Legal Aid Fund, Kangra.
It further held that the insurers were neither necessary nor proper parties to the consumer complaint. However, the nursing home was permitted to seek indemnification under the applicable insurance policy, with the concerned insurer directed to process and settle the claim within 30 days of receiving it.
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Takeaway
The case highlights the importance of proper blood storage, timely transfusion and accurate medical records. The commission held that hospitals must strictly follow transfusion protocols and maintain clear, consistent records, particularly when an adverse reaction occurs.
Aggrieved consumers may contact the consumer helpline in their respective states (Himachal Pradesh: 1800-180-8087) or call the National Consumer Helpline at 1915 for assistance.
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