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Not Sending Medical Records To The Next Hospital During Transfer And Not Insisting For Records From The Previous Hospital At Transfer- Both Hospitals Held Negligent.

Not sending medical records to the next hospital during transfer and not insisting for records from the previous hospital at transfer- Both hospitals held negligent.

K.Kotaiah v. Dr. T. Anjaiaj & ors

National Consumer Disputes Redressal Commission, New Delhi

Facts of the case

• The patient visited the first Hospital (OP5) with skin lesions and was started on local ointments. On follow up Tab. Dapsone was started after investigations.  After approximately 1 month, the patient came back with a history of fever and rashes all over the body and was admitted. After 6 days , the patient was transferred to the second hospital (OP3). After 4 days, the patient was again transferred to the third hospital (OP6) where the patient died.
• Medical expert committee of three eminent doctors appointed by the court held that there was no negligence.

Patient allegation/s of medical Negligence.

• It was alleged that the First hospital (OP5) transferred the patient to the second hospital (OP3) with just a renewal letter. No treatment history not investigation reports were handed over to the second hospital (OP3).

• It was alleged that the second hospital (OP3) also did not insist on the treatment history and medical history from the first hospital (OP5) while receiving the patient.

Doctor’s Defence

• It was stated that the first hospital (OP5) had an institutional protocol, as it was a railway hospital, of transferring patient with just a referral letter and not with treatment/ investigation records. It was further pointed to the court that the doctors of first hospital (OP5) had in fact visited the patient in the second hospital (OP3) and had discussed the treatment history with the doctors of the second hospital (OP3) and the same was reflected in the medical records of the second Hospital (OP3).

• It was stated by the second hospital (OP3) that it was the duty of the first hospital (OP5). To give treatment /investigation records during transfer or immediately thereafter. It was further stated that the duty  of the second hospital (OP3) was to only treat the patient after transfer.

Finding of the court

• The court observed that the first hospital (OP5) should have given treatment and medical details of the patient’s treatment along with the referral letter either at transfer or immediately thereafter.
• The Court held that the second hospital (OP3) was negligent in not insisting on the treatment/ investigation records of the first \hospital (OP5) while receiving the patient or subsequently.
• Hence the doctor involved with the patient were not held negligent whereas both the hospitals (OP5&3) were held negligent.

Suggested Precautions

1. Every patient transferred should be given complete details of the treatment/ investigations up to the time of transfer. This duty of the transferring hospital also extends to the medical records prepared in the transit. Specifically record the documents ot the copies given to the patient/ attendants in the transit or discharge note and take the acknowledgment of the patient/attendants having received the same.
2. On the other hand, the duty of the receiving hospital is to insist on medical records of the treatment/ investigations, and in case the same is lacking, this fact must be specifically documented. Emergencies are Exceptions.
3. Internal SOP’s/ Guidelines of the hospital/institution must be in tune with the accepted medical practice prevailing at that point in time. Efforts must be made to revise the internal guidelines.
4. A patient can be shifted to another hospital immediately, without medical records, if it is an emergency. But at the first available opportunity, the transferring hospital must ensure that the requisite medical records reach the other hospital.