Medical Negligence

My sister, aged 47, was admitted to a Nursing home for routine elective surgery after an extensive pre-operative assessment and clearance. She underwent a hysterectomy, appendectomy and repair of a ventral hernia with a prolene mesh on 12/03/2010. She was sent to the SICU (Surgical Intensive Care Unit) for close monitoring. At 06:30 pm, she was stable with a normal heart rate of 80 and a normal blood pressure. From 11 pm onwards, she complained of abdominal pain and distension with a rising heart rate, falling blood pressure and increased respiratory rate. Chart review shows that the RMO (Resident Medical Officer) monitored her every 30-60 minutes from 01:00 am of 13/03/2010. The Anaesthetist, was called for advice at 11 pm of 12/03, 1 am, 1:30 am, 3:30 am, 4:15 am, 4:30 am and 6:30 am of 13/03/10. Every time it was felt that the problems of elevated heart rate, pallor, decreasing blood pressure and decreasing urine output was due to pain and pain medications were administered. Hb / PCV was not ordered till 4:45 am. Haemoglobin results returned at 06:30 am at 4.6 gm/dl where pre-operative Haemoglobin was 11.6 gm/dl. Only then was the blood transfusion started.

My sister went into hypovolemic shock from post-operative bleeding and had a Cardiac Arrest at 06:30 am of 13/03/10. She was resuscitated and taken back to the operating theatre for re-exploration and no obvious bleeding source was detected. Consequent to this she went into multi-organ failure – liver, kidney, pancreas, DIC (Disseminated Intravascular Coagulation) and did not respond to further measures and passed away at 03:55 am on 16/03/2010.

On examination of the records provided by the nursing home after my sister's demise, some of the concerns that came across were:

1.                  Why was the bleeding not diagnosed earlier despite clinical evidence of post-operative haemorrhage, i.e. (increased Heart rate, decreased blood pressure, pallor, abdominal distension and decreased urine output) ?

2                  Why was there no Critical Care Specialist overseeing the Surgical ICU with authority to override inappropriate orders and assessment when the patient’s life is at risk? Considering the fact that this particular nursing home publicizes Intensive Care Units in their facility, it appears that it is not the norm at for them to have 24-hour Critical Care Specialist(s). This unfortunate turn of events could have been prevented if  the intensive care units at the n.home were correctly staffed with 24-Hour Critical Care specialists as evident with other reputed hospitals/intensive care units in India and abroad.

3                Why was blood transfusion not started earlier?