FROM THE PRESS
Consequences of illegible prescriptions
Heard the doctor who wrote a letter to his wife and she had to take it to the chemist to have it read? Doctors have traditionally been known for their bad handwriting. And danger lurks behind every such scrawl.
Recently a US court slapped a heavy penalty on a doctor who wrote a prescription that the druggist read wrongly, and gave the wrong medicine leading to the death of a patient. In India, this is a situation just waiting to happen.
In a private nursing home in south Delhi, a doctor wrote a prescription for ‘injection CP’ for chloramphenicol for typhoid. The nurse took it to mean chloroquin phosphate for malaria, as a result of which the child suffered liver toxicity.
Hidden danger lurks behind doctors’ scrawl. Radhika D Srivastava : The Times of India, October 27, 1999.
Hospital refuses to release patient’s papers
In complete violation of a court directive on patient’s rights, the cardiology department of the government-run JJ hospital refused to release angiography films of a 57-year-old patient who wants to get an angioplasty done in a private hospital. When the patient asked Dr NB Bansal, associate professor of cardiology at JJ, for the film to show it to a consultant, he was told it belonged to the hospital. Claiming that the court order is being interpreted by patients to suit their convenience, Dr Bansal said it is not binding on the hospital to hand over the angiography film in this case. Asked why the hospital wanted to keep the film, he said some material has to be retained for reference in case the patient wanted to return for treatment.
JJ gives heart patient shock treatment. Rajiv Sharma.Indian Express, December 11, 1999
Surrogate grandchild?
The parents of a 36-year-old man who died in a road accident are fighting a legal battle to use their son’s sperm to bear a child through a surrogate mother. The hospital which took the man’s sperm from his body before he died feels the the parents’ request lies outside the scope of the man’s stated wishes for use of his sperm after his death. The man’s girlfriend has refused to have her dead boyfriend’s child.
Surrogate mother wanted for dead son’s sperm.The Age (Australia), December 12, 1999.
Testing for HIV without consent
A GP in England who arranged for the blood of five patients to be tested for HIV without their consent was found guilty of serious professional misconduct and severely reprimanded by the General Medical Council.
Dr John Nicholls was also found guilty of failing to counsel the five about having the test, and of failing to give adequate counselling to another patient whose consent he had obtained.
In each case, the committee found that there was insufficient clinical indication to justify testing the patients for HIV. One was seeking the emergency contraceptive pill because she had been raped, and the others presented with a range of problems including chronic sinusitis, which failed to respond to antibiotics, concern about failure to gain weight, and oral thrush. All the test results were negative.
Several of the patients told the GMC they were “shocked” to discover from Dr Nicholls’s partners in 1997 that blood samples taken from them had been tested for the virus.
The practice came to light while Dr Nicholls was on holiday and another partner saw the results of the blood test on Ms F, the patient with chronic sinusitis, in his tray.
GP reprimanded for testing patients for HIV without consent. Clare Dyer:BMJJanuary 15, 2000.
Childrens’ drugs not tested for safety
The majority of drugs given to children have not been tested for safety on children, according to a study in England, Sweden, Germany, Italy and the Netherlands. Two-thirds of the drugs prescribed to children were not licenced for use in children or were used for purposes beyond that labelled –which can mean a higher risk of adverse drug reactions.
The Sunday Age(Australia). January 16, 2000
Made case studies without their consent
Shipped out of two of Mumbai’s biggest civic-run hospitals (Sion and KEM) in ambulances in the dead of night, six patients were headed for an unknown destination. They had been told they were being transferred to the trust-run Bombay Hospital for reasons varying from a “medical conference” to “further investigations”. What they didn’t now was that they were to be used as case studies for six post-graduate neurosurgery students, who were taking their practical examination at Bombay Hospital’s medical college. The patients are furious at the deception. All six say their consent had not been taken to act as specimens. Najmuddin, scheduled for surgery the next week to remove a brain tumour, was informed late one night that he had to be transferred to Bombay hospital for ‘further investigations’.” We became extremely worried as we thought he had suddenly taken a turn for the worse,” says his brother.
All the doctors interviewed agreed that consent was essential for such situations. The dean of Bombay Hospital’s institute of medical sciences where the exam was conducted says there must have been a “communication gap”.
Dr Keki Turel, professor and head of neurosurgery, Bombay Hospital and convenor of the exam, insists that it is routine for patients to be transferred to a medical college where an exam is underway. In any case, they were not administered any treatment, nor were any invasive procedures carried out. It is not his duty to apprise patients of the reason for their transfer; he is responsible solely for conducting the exam.
Students get ‘unwitting’ patients for practical exam. Rajiv Sharma: Indian Express. January 29, 2000
Regulation for gene therapy
Like all risky medical research, better regulation is needed for gene therapy,said Dr Arthur Caplan, professor and director of the Center for Bioethics at the University of Pennsylvania in Philadelphia, USA, speaking at the New York Academy of Sciences. A gene therapy experiment at the University of Pennsylvania led to the death of 18-year-old Jesse Gelsinger who had an inherited metabolic disorder.
The press hinted that researchers’ ties to biotechnology companies might compromise studies. Dr Caplan pointed out that such ties had been encouraged by federal law for 20 years, to bring research efforts to the market place and benefit patients. Almost all leading researchers had such ties.
“The area is rife with hypocrisy,” said Dr Caplan, who enrolled in a clinical trial himself and saw problems with incomplete information and coercion of subjects. “The system is broken. It’s been broken for a long time. It took gene therapy to make it evident. Monitoring is non-existent. Adverse event reporting is a joke.”
Dr Caplan recommended tougher monitoring, debriefing of at least five per cent of study subjects by institutional review boards, random audits of institutions conducting trials, and better coordination between data safety and monitoring boards and institutional review boards to share information on adverse outcomes. Finally, he suggested a “no fault” insurance fund to compensate for medically related injuries instead of the current system of malpractice lawsuits.
US faces ethical issues after gene therapy death. Janice Hopkins Tanne:BMJJanuary 29, 2000.
Consumer courts take negligence seriously
A child born at a private nursing home in Delhi is sent to another hospital where it dies within a few hours of admission. A post-mortem reveals severe injuries on the skull, chest and arms, apparently caused by the improper use of forceps.
Harbans Lal went to a doctor for treatment of a fractured arm – and ended up having to have the arm amputated. The district consumer disputes redressal commision found both doctor and hospital guilty of deficient services and fined them Rs 1.5 lakh and Rs 2,000 costs. When the doctor appealed to the state commission, it was found that they were claiming to be bone specialists, when they were neither registered nor qualified to practice allopathy.
The court has ruled that consumer courts are competent to rule on deficiencies in medical service from negligence, and the courts are taking such cases very seriously.
Killing in the name of medicine: the consumer courts are taking cases of negligence seriously.Business Standard, Calcutta, February 5, 2000
Amputation for a psychological disorder
In Scotland, a surgeon amputated the legs of two men with a rare psychological disorder known as apotemnophilia, in which patients believe they will be normal only once a limb has been removed. Such patients often cause harm to themselves to achieve this goal.
The surgeon operated after getting permission from the hospital’s chief executive and medical director, and after talking to his defence body and the ethics committee of the General Medical Council. The patients went through a psychological assessment and counseling beforehand. The surgeon, who did not accept a fee for the surgery (the hospital was paid £3000), said the patients’ lives had been transformed. “At the end of the day I have no doubt that what I was doing was the correct thing for those patients.”
The current chairman and board members of the trust which runs the hospital learnt of the amputations only when the surgeon informed them that he was assessing a third patient for the same procedure.
The trust announced a temporary ban on further amputations. Such operations were not ruled out, but a strict procedure would have to be followed.
Surgeon amputated healthy legs. Clare Dyer: BMJ, February 5, 2000.
Pneumonia, not broken bones
The out patient department diagnosed him as an ‘orthopaedic case’, and the orthopaedic surgeon thought he was an alcoholic. Chhotelal Ramlal Chauhan spent the day being passed around in various departments of the civic-run Cooper hospital in Mumbai, and the only treatment he got was a glucose injection and some antacids. Within an hour of being sent back home, he collapsed and died.
A post-mortem examination revealed that the 20-year-old was suffering from advanced pneumonia, which could have been picked up through a clinical exam and a simple chest X-ray. He also should have been admitted immediately into the hospital.
Ram Vilas Yadav, a relative who works in the hospital, says poor patients are given little if any treatment in this hospital. Dr S N Bhatia, in charge of municipal peripheral hospitals, said she had ordered an inquiry into the case.
Pneumonia patient diagnosed as an orthopaedic case, dies an our later. Rajiv Sharma: “Indian Express, Mumbai, February 17, 2000.
HIV positive mother refuses drugs
Gill Hickman decided to have a child despite knowing she is HIV positive.But what will be even more difficult for many to comprehend is how this intelligent and devoted mother declined to take an antiviral drug during pregnancy to reduce the risk of passing on the infection to her unborn child. Drug therapy has been shown to reduce (maternal-foetal HIV) transmission by about two thirds.
Ms Hickman decided to become pregnant some years after she discovered she was HIV positive. The hospital told her she had a one in seven chance of having an HIV positive baby. When she became pregnant doctors, who were supportive of her decision to have a child, offered her AZT, a common anti-viral drug. But she refused to take it. “I… am a bit suspicious of drugs and their side-effects. Also, I lived through the period when the Thalidomide babies were born, and I just didn’t want to put my baby at risk of anything.”
Nor did Ms Hickman opt for a Caesarean section, which is known to significantly reduce transmission of the virus. She did, however, decide to bottle-feed. Breastfeeding has been found to double the rate of transmission in the absence of other interventions. (Women who opt for all three interventions-anti-HIV drugs, delivery by Caesarean section and bottle-feeding-run a less than five per cent risk of transmitting the virus to their child.) Tests have shown Malachai is HIV negative.
Ms Hickman is not the only HIV-positive mother to question drug treatment. Last year an HIV-positive mother in the UK and her husband fled the country when a court ordered that their four-month-old daughter be tested for HIV against their wishes. Camden Council in north London had applied to the court under the 1989 Children Act for an order to test the girl, believing that if positive, she had a right to treatment. After researching the virus, the 33-year-old mother, who was breastfeeding her child, had become convinced that scientists were wrong in believing that HIV was the sole cause of AIDS. She had never taken any medication and claimed to be in perfect health. The judge did not order her to stop breastfeeding.
Baby, take a chance on me. Julia Stuart:The Independent February 25, 2000
Private hospitals not for the poor
Despite receiving government subsidies, many of Delhi’s private and charitable hospitals have failed to meet their obligations to poor patients. ‘Critical Condition’, published by Workers’ Solidarity, says the increasing dominance of the private sector in health care and the trend to privatise charitable hospitals have made health services inaccessible to the poor.
The report is based on a survey of wages, working conditions and terms of employment of Class IV workers in eight of Delhi’s largest private hospitals. “Though these hospitals and institutes have received public benefits in the form of subsidised land, tax deductions, import exemptions and donations, they have failed in providing the stipulated free or cheap health services,” said a spokesperson of Workers’ Solidarity. The report alleges that Apollo Hospital, in which the government has a 26 per cent stake, keeps 200 beds meant for the poor mostly vacant, to avoid spending money. The hospital has a long-term lease on 15 acres from the DDA at the rate of just Re 1 a month.
Apollo hospital’s CEO said the hospital had a special block for poor patients, who are referred by the government hospitals. The report cites the general OPD in Moolchand hospital that was given nine acres of prime land on Ring Road and a grant of Rs 3.5 lakh (after Partition), as being wilfully allowed to deteriorate. The charge in a paid OPD is as high as Rs 250 per visit.
Private hospitals ignore the poor: report. United News of India: Indian Express. February 29, 2000.
Doctor’s services deficient
The Consumer Court, Mumbai Suburban District, fined a doctor in Andheri Rs 4,000 (Rs 2,000 fine, Rs 1,000 refund of charges and Rs 1,000 court costs) for being ‘deficient in services’ with ‘outdated equipment.’
The directions were passed by the Consumer Disputes Redressal Forum on a complaint filed by George Mathew against Dr JT Shah of the Sandeep Clinic, Andheri (E). The doctor was on a panel of physicians authorised to conduct medical tests for candidates selected for employment in Saudi Arabia. In 1997, Mathew who was selected for a job there approached Dr Shah for a medical certificate, underwent medical exams and paid Rs 1,000 as fees. When he went to collect the reports the next day he was told he had failed the test as he was HIV positive, but he was not given the test report. Repeated tests elsewhere showed him to be HIVnegative, but the doctor refused to accept the labs’ findings, as a result of which Mathew lost a job paying Rs 25,000 a month. Mathew filed a case in the consumer court, asking for compensation of Rs eight lakh (later reduced to Rs 2 lakh ). Dr Shah argued that the case was fabricated, and anyway was invalid since it was filed not by Mathew but by his attorney. But the court found the doctor guilty and deficient in service.
Express News Service: Indian Express, March 9, 2000.
Sorry, no drugs
Can one of Mumbai’s largest municipal hospitals run for three months without syringes, surgical gear, cotton, drugs and even vitamins? The BYL Nair hospital has pulled off the impossible. Even as it opts for a multi-crore makeover, it admits patients to its 32 wards without drugs and surgical equipment. Marble and ceramic tiles lie stacked all over as workmen renovate the premises. And ward walls are covered with lists of ‘out-of-stock’ drugs The diabetic patients department has no insulin injections, the trauma ward has no nifedipine (a hypertension drug) and anaesthetists say stocks of neostigmine (to revive anaesthetised patients) ran out long ago. Patients and relatives are asked to buy the drugs themselves.
Remarks a resident at the OPD, “It is stunning that the administration can afford such a makeover when patient care is in jeopardy. Patients are asked to make their own arrangements for even basic items like bandages, plaster and commonly available drugs. There have been shortages earlier, but the situation has never been this bad. Some OPD patients cannot afford the drugs and just leave to return in worse condition. Except for the acting dean Dr HS Dhawale who admits to the shortage, the civic authorities say all is hunky-dory. The additional municipal commissioner says he is not aware of the situation. The municipal commissioner remarks: “The beautification has nothing to do with the shortage, if any.”
Face-lift for Nair, healing can wait. Manju Mehta:Indian Express Newsline. March 14, 2000.
Negligent gynaecologist
The National Consumer Disputes Redressal Commission ordered Dr Mangla Bansod, a Nagpur-based gynaecologist, to pay Vijay Mankar compensation of Rs 2.5 lakh for her negligent handling of his wife’s pregnancy, leading to her death.
On May 31, 1990, Dr Bansod prescribed medication to Lata Vijay Mankar when she complained of discomfort at a check-up a week before her delivery date. She was admitted in distress to Dr Bansod’s nursing home that night, but was left untreated for five hours before being taken into the labour room. The doctor eventually came out to inform the family that the child had been delivered — also asked them to arrange blood for the mother. While this was being done, Lata was shifted to a government hospital, without the relatives’ consent. The government hospital said she was dead on arrival. Dr Bansod claimed Lata died because she had taken drugs prescribed by her doctor brother-in-law. After recording the evidence of expert witnesses, the commission concluded that Dr Bansod was negligent.
Doc to pay Rs 2.5 lakh for negligence. Press Trust of India: Indian Express. March 18, 2000
Informed consent for postmortems
The procedure for getting informed consent for postmortem examinations in the UK is to be changed. The Royal College of Pathologists’ guidelines require better training of staff who must speak to relatives to allow postmortem examinations. The impetus: parents of children at the Bristol Royal Infirmary, who died following heart surgery, were not asked permission to retain the hearts from the children after postmortem examination.
It is hoped that the guidelines will promote public support for postmortem examinations whose credibility has been affected by the recent findings. In the past, doctors and pathologists rarely discussed the details of postmortem examinations, and it was assumed that once tissues had been lawfully obtained it was ethical to use them for research and education purposes without asking for permission.
Relatives to be told if organs are retained after postmortem. Zosia Kmietowicz :BMJ: March 25, 2000.
Marketing of milk substitutes
A former employee of Nestlé has publicised internal company documents that he says provide evidence that the company has breached the international code on marketing breast milk substitutes.
The documents are reproduced in Milking Profits, a report published by The Network, a non-governmental organisation in Pakistan. The report highlights Nestlé’s gifts to doctors for promoting its products, direct marketing to mothers and the provision of free supplies of breast milk substitutes.
The vice president of Nestlé denied allegations of malpractice: “As anywhere in the world, Nestlé’s marketing of breast milk substitutes in Pakistan is in line with the World Health Organisation code, and if errors occur they are promptly corrected.”
