J Douglas Louis lost his voice after undergoing thoracotomy on 31 October 2003 at Manipal Hospital to remove his carcinoma-affected left lung.
Supreme Court of India. (iStock)
The Supreme Court has spoken up for a man — whose speech was impaired after an alleged botched administration of anaesthesia — nine years after his death.
The top court recently ordered the Manipal Hospital in Bengaluru to pay a compensation of ₹10 lakh to the family of the late J Douglas Louis, who lost his voice after undergoing thoracotomy on 31 October 2003, at Manipal Hospital to remove his carcinoma (a type of cancer)-affected left lung.
Thoracotomy is a surgical procedure in which an incision is made between the ribs to see and reach the lungs or other organs in the chest or thorax.
After the surgery, Louis’s voice became hoarse, and he complained of difficulty in speaking. Doctors, however, assured him he would regain his voice after a few months.
Dr Nithyanand Shetty, a cardiothoracic surgeon, conducted the surgery with cardiac surgeon Dr Sameer Rao assisting him.
The patient was discharged from the hospital on 10 November 2003. However, he did not regain his voice as assured, despite undergoing therapy.
Subsequent examinations revealed posterior subluxation (partial dislocation) of the left arytenoid (cartilage at the back of the larynx) and anterior subluxation of the arytenoid with left vocal cord paralysis.
“Dr EV Raman, the Head of the ENT Department at Manipal Hospital, orally acknowledged an issue with the left arytenoid during laryngoscopy on 31 October 2004. However, he hesitated to provide a written confirmation, but offered a refund,” Louis later said.
He consulted Dr DM Anklesaria in Mumbai for a second opinion, who confirmed the diagnosis on 23 October 2004.
For the remaining 12 years of his life after the surgery, the speech impairment deprived Louis of a promotion at Trans World Travels, where he had been working as an area manager.
Louis reportedly realised that the hospital’s negligence and failure to consult the ENT Department had led to the hoarseness in his voice. He had also claimed that the anaesthesia, administered by a trainee anaesthetist, using a double-lumen tube, cuffs, and stylet (aluminium), violated the protocol.
The Head of the Anaesthetic Department was supposed to administer the cardiothoracic anaesthesia using a double-lumen tube, but the hospital reportedly assigned another doctor and a trainee for the task. The improper insertion of the tube by the trainee injured Louis’s vocal cords, resulting in irreparable damage.
Louis approached the District Consumer Disputes Redressal Forum in Bengaluru, seeking a compensation of ₹18 lakh. The forum awarded him ₹5 lakh as compensation on 10 May 2006, and an additional ₹5,000 towards court expenses.
The man challenged the lesser compensation in the National Consumer Disputes Redressal Commission (NCDRC) before he died in 2015.
Louis’s death marked the beginning of his wife’s fight for justice.
In November, the NCDRC emphasised that lung cancer surgery was a specialised procedure requiring proper and expert anaesthesia. The use of a double-lumen tube for intubation demanded significant experience and expertise.
In Louis’s case, the Commission said, the Head of the Department of Anaesthesia, who was supposed to administer anaesthesia, did not perform the task. Instead, it was carried out by an anaesthetist on deputation to the hospital for training in cardiac anaesthesia.
“In our view, the delegation of a crucial duty itself was a breach of duty of care. It was not a reasonable practice, as the better degree of care and skill was expected from Manipal Hospital,” the NCDRC said in its judgement.
The NCDRC further said that the dislocation of the left arytenoid was only due to traumatic cause, which subsequently led to vocal cord paralysis. The Recurrent Laryngeal Nerve (RLN) injury would not cause dislocation of the arytenoid. It was the result of faulty insertion of the double-lumen tube while administrating anaesthesia.
“The complainant in her revision petition is seeking enhancement of compensation, but in our view, the State Commission has awarded just and proper compensation,” NCDRC said.
The judgement was not acceptable to Louis’s wife. She approached the Supreme Court for an enhanced compensation.
Her efforts paid off. An apex court Bench of Justices Hima Kohli and Ahsanuddin Amanullah directed the hospital to increase the compensation to ₹10 lakh with interest.
Counsel for the petitioner highlighted that the deceased, employed as an area sales manager, suffered a decline in his career due to the hoarseness in his voice. The counsel argued that the appellant virtually lost his voice and continued in the same position without promotions from 2003 until his demise at the end of 2015.
Throughout the period, he remained on the initial monthly salary of ₹30,000 that was set at the beginning of his employment.
“Given the aforesaid facts and circumstances of the case, we are of the opinion that the District Forum ought to have taken all the aforesaid aspects into consideration for arriving at a rightful compensation payable to the deceased which in the instant case, has not been done,” the court said on 10 February.
“Mere reliance on medical literature would not be sufficient to exonerate the hospital from its duty of ensuring that the Head of the Department, Anaesthesia, ought to have inserted the double-lumen tube. Instead, he was not available and the task was delegated to a trainee anaesthetist.” the court observed while disagreeing with the contention of the respondent hospital.
The compensation initially awarded by the district forum has been doubled. Additionally, simple interest has been calculated at a rate of 10 percent per annum from the date of filing the claim. This is subject to adjustments for any amount already released to the patient.
Manipal Hospital said the surgery was performed by a team of doctors led by Dr Shetty. After the surgery, the patient was advised to follow-up with Dr N Shetty at Medinova Hospital. He underwent chemotherapy as recommended by an Oncologist.
The hospital’s counsel argued that the complaint was filed based on the opinions of two experts who attributed the patient’s condition to the alleged negligence of the anaesthetists during the surgery.
One of these experts, Dr Shankarshana, suggested seeking a second opinion from Dr DM Anklesaria.
Dr Shankarshana, after examining the patient on 15 October 2004, and conducting Flexible Fiber Optic Laryngoscopy (FFOL), claimed that the arytenoid cartilage was posteriorly dislocated due to external trauma or faulty instrumentation during anaesthesia, resulting in severe hoarseness of the voice.
However, the report and test film were not produced as evidence for the alleged dislocation of the arytenoid cartilage causing hoarseness.
The counsel further argued that the complainant refused to undergo FFOL at the hospital under the supervision of Dr EV Raman. The certificate issued by Dr Anklesaria was deemed inconsistent with other certificates, and the expert evidence was criticised for being unreliable.
The hospital suggested that the expert appeared to be biased, and the complainant’s evidence lacked support from medical literature.
On 14 November 2005, Manipal Hospital examined the three expert witnesses, considered more qualified than Dr Shankarshana, who unequivocally denied any faulty intubation during the surgery.
They asserted that a high-quality Endotracheal Tube (ETT) was used, and there was no evidence of error, mistake, or negligence. The surgery, classified as high risk due to the removal of lymph nodes along with RLN, could have resulted in some damage to the left Recurrent Laryngeal nerve (RLN), leading to hoarseness.
Vocal cord paralysis, which could cause arytenoid dislocation, was ruled out due to the absence of respiratory distress or symptoms during the immediate postoperative period.
The hospital’s counsel supported the arguments with medical literature, contending that subluxation of the arytenoid cartilage could occur spontaneously and, even if caused by intubation, could reposition itself without treatment.
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