NCDRC on Fortis Hiranandani Hospital: Failure to Investigate IV Fluid Reaction Amounts to Service Deficiency
Case: Mrs. Richa Navendu Shrivastava v. Fortis
Healthcare Ltd. & Ors.
Consumer
Complaint No. 292 of 2013 | Order dated:
1 October 2025
Bench:
Justice A. P. Sahi (President) & Mr. Bharatkumar Pandya (Member), National
Consumer Disputes Redressal Commission (NCDRC)
Background
The NCDRC has held Fortis Hiranandani
Hospital, Navi Mumbai, liable for deficiency in service
after finding that it failed to investigate an adverse reaction to
intravenous (IV) fluids that led to the death of a patient
admitted for a routine surgery.
The complaint was filed by Mrs.
Richa Shrivastava, whose husband Navendu Shrivastava (42)
was admitted on 12
December 2012 for a simple piles operation. The case exposes how
gaps in hospital coordination and lack of immediate investigation into an
adverse medical reaction can amount to actionable negligence under consumer
law.
📄 Key Facts of the Case
·
The
patient was scheduled for surgery at 3 PM on 12.12.2012, but it
was postponed due to non-availability of the operation theatre.
·
He was
kept “nil
by mouth” for nearly 20 hours and administered IV
fluids around 4 PM.
·
Within
minutes, he developed shivering, high fever (103°F), vomiting,
and rashes, yet no senior doctor promptly attended him.
·
Despite
clear symptoms of an adverse IV reaction, no
inquiry or testing of the fluid was initiated.
·
The
patient’s condition deteriorated; he was shifted to ICU later that evening and died on
15 December 2012.
· Crucially, no sample of the IV fluid was preserved or sent for analysis
Allegations
by the Complainant
·
Prolonged fasting and neglect: keeping the patient without food for
almost a day violated medical norms.
·
Administration of contaminated IV fluid caused the fatal reaction.
·
Failure to investigate or preserve evidence of the reaction.
·
No pre-anaesthesia evaluation or informed
consent.
·
Manipulation of records to conceal negligence.
Forensic expert Dr. Rajendra S. Bangal
supported these claims, concluding that poor coordination, violation of fasting
protocols, and failure to investigate constituted deficiency in service.
🏥 Hospital’s Defence
·
The
hospital claimed the patient died of leptospirosis, a bacterial
infection allegedly confirmed later.
·
It
argued that the IV fluid was not contaminated, as blood
culture reports were negative.
·
According
to its counsel, doctors had continuously monitored the patient and followed all
protocols.
🧪 Conflicting Expert Opinions
Multiple committees—J. J. Hospital,
Directorate of Medical Education & Research (Maharashtra), and state
medical boards—submitted differing conclusions.
To resolve the conflict, the NCDRC sought an independent opinion
from AIIMS, New Delhi.
The AIIMS medical board
reported:
“As the patient was fasting, he was started
on intravenous fluids due to which he probably developed adverse fluid
reactions, which was managed accordingly.
The patient subsequently went into sepsis and succumbed.
… No clear count of deficit in management can be ascertained except
administration of IV fluid causing adverse reaction.”
While AIIMS stopped short of confirming
negligence, it acknowledged the probable link between IV fluid
administration and subsequent sepsis.
⚖️
NCDRC’s Observations & Findings
After reviewing the entire record, the
Commission held that:
·
There
was no
forensic or chemical examination of the IV fluid—a grave lapse
for a tertiary-care institution.
·
The
hospital failed
to investigate the patient’s immediate reaction.
·
AIIMS findings of an “adverse reaction to IV fluid
progressing to septicaemia” could not be ignored.
·
The absence
of confirmatory tests for leptospirosis weakened the hospital’s
defence.
The Commission therefore ruled that the failure
to investigate and document the IV fluid reaction amounted to deficiency in
service under the Consumer Protection Act.
🧭 Legal & Policy Significance
·
Defines
deficiency
to include omission
to investigate medical complications—not just errors in
treatment.
·
Establishes
that post-reaction
inquiry is a mandatory part of hospital service obligations.
·
Reinforces
institutional accountability—hospitals, not only individual doctors, can be
liable for systemic lapses.
💡 Implications for Hospitals
·
Must
implement adverse-event
investigation protocols: immediate review, documentation,
sample testing, and reporting.
·
Maintain
coordination
between consultants, anaesthetists, and nursing staff.
·
Preserve
all clinical
evidence after unexpected reactions.
·
Inform
patient families transparently and document every step of care.
👥 Lessons for Consumers & Advocates
·
Patients’
families should demand written records and explanations for sudden medical
reactions.
·
Under
the Consumer
Protection Act, 2019, hospitals can be held liable for failing
to investigate or concealing evidence.
·
The
case reinforces that service deficiency can stem from
institutional inaction even when the initial cause is
uncertain.
📘 Conclusion
The Fortis Hiranandani Hospital
ruling affirms that medical responsibility extends beyond
treatment to vigilance and investigation.
By holding the hospital accountable for not probing a clear IV fluid reaction,
the NCDRC has broadened the scope of patient safety and consumer rights in
India’s healthcare sector.
It is a strong reminder that silence and inaction in the face of a
medical emergency amount to negligence.
References:
·
Mrs. Richa Navendu Shrivastava v. Fortis
Healthcare Ltd. & Ors.,
Consumer Complaint No. 292 of 2013, NCDRC Order dated 1 October 2025.
·
AIIMS
Medical Board Report dated 21 December 2019.
·
Directorate
of Medical Education & Research, Govt of Maharashtra Report (2016).
Source: Publicly available NCDRC order (uploaded
case file).
No comments:
Post a Comment