When knowledge can be harmful

Dr. Subas Chandra Dash vs State Of Orissa on 27 February, 2017 Orissa High Court

MD (Obstetrics & Gynaecology) doctor inserted a vaginal tablet to induce delivery following which there was a gush of (? Amniotic) fluid along with (? labour) pain in a G3P2 patient. The doctor attempted forceps delivery unsuccessfully following which severe bleeding started. Patient was referred to a higher centre where no intervention could be done and patient and child both expired. Doctor took defence that patient was never admitted nor did he do any procedure but it was a case of abruptio placentae with APH and he only gave ceftriaxone injection in OPD and referred the patient.

SDJM after perusal of chargesheet submitted by police after medical board’s opinion took cognizance of the offence under Section 304 Part II . This order was challenged in high court by the doctor. The high court observed that the doctor was qualified and the nursing home was duly registered with appropriate authorities, under Odisha Clinical establishments Act, PCPNDT Act and Pollution Control Board. But he should not have attempted to do any thing in a case of antepartum hemorrhage (as mentioned in OPD register) but referred her straightaway whereas evidence of witnesses proved that he had attempted to induce labour pains in her and applied forceps.

Issue in question was Section 304 Part II wherein death is caused by doing an Act with knowledge that the act is likely to cause death but without intention to cause death. The HC set aside the order as regards Section 304 Part II but directed the Magistrate to proceed against the doctor under Section 304 A but confined to stage of cognizance. Guilt or otherwise of the doctor would be decided by court during the course of trial based on evidence.

The HC judgment raises some issues to my mind; 
1) “Forceps delivery is appropriate only in a place which has facilities to conduct caesarean section”. If so then why are we training Dais and midwives and nurses to conduct assisted vaginal delivery for maternal exhaustion.
2) Knowledge that Act performed is likely to cause Death would be present in minds of all surgeons conducting any surgery / procedure. Would then all operative deaths be henceforth charged with Section 304 Part II (Even though this was not done in this case). Would it have been better if the doctor was not qualified hence not supposed to have knowledge that his “Act” could result in death. Obviously no qualified doctor has intention to kill someone but he has gained knowledge through his training that death can result from the surgery he is about to perform to heal the person.
3) Proof that uterine perforation due to forceps was cause of bleeding and death not available in the absence of any surgical findings or a post-mortem. If so then why could other natural causes of antepartum hemorrhage not have caused death. 
4) We already are aware of Supreme Court ruling that surgery cannot be done in a nursing home which does not have ICU. Now as per this judgment we cannot conduct assisted delivery if we do not have operation theatre ( which we cannot have without an ICU). Hence presumably we cannot conduct assisted delivery in a place which does not have an ICU . Maybe tomorrow we will also need ICUs for normal deliveries and to give vaccinations.

Dr Neeraj Nagpal 
Convenor,Medicos Legal Action Group, Managing Director MLAG Indemnity,
Ex President IMA Chandigarh
Director Hope Gastrointestinal Diagnostic Clinic,
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