Fortis hospital dengue death: Several wrongs but no clear villain
Gurgaon’s Fortis Hospital billed the family of a seven-year-old girl, who died of dengue in September, for 660 syringes and 2,700 gloves during her 15-day hospital stay.
For those who have been forced to re-examine the two weeks over and over again, singular moments define the time between September 1 and 14.
For Jayant Singh, an IT professional based in Dwarka, it was while he drove from one hospital to another on the night of September 14, requesting a certificate pronouncing his seven-year-old daughter dead.
“It was just like in the movie Gabbar where Akshay Kumar goes from hospital to hospital begging for a death certificate for his child.”
For his wife, Deepti Singh, it was when, having finally brought the body of her dead child home the next morning, she was asked by the ambulance driver to return the sheet in which it was wrapped.
“He said he must return it to the hospital because it was attached with a chip, but how could I have taken it off — her body had swollen, her face had turned black. He said I should otherwise pay him Rs 700 for the sheet.”
For Bhavdeep Singh, the CEO of Fortis Healthcare, the moment only came in the third week of November, when, watching prime-time TV debates, he was struck by how his hospital would appear to “someone who just landed in Delhi from Mars”. “They must think that anyone who steps into Fortis for treatment is mugged, robbed, assaulted or killed.”
For Narottam Puri, medical adviser at Fortis Healthcare, it came last week when a friend and fellow doctor who had been struggling to persuade his son against a career in medicine called him to say that his son had changed his mind. “He came into the room and told my friend, ‘Papa, I don’t want to be a doctor anymore.’”
What happened between September 1 and 14?
At 10:30pm on August 31, Jayant and Deepti brought their daughter, Adya, to the Fortis Memorial Research Institute in Gurgaon in a state of emergency. Down with dengue since August 27, the seven-year-old had by now developed a dangerous form of the mosquito-borne disease called Dengue Shock Syndrome. Unprepared to deal with the condition, doctors at their local Rockland Hospital, where she had first been admitted, had advised that she be transferred to a paediatric ICU (PICU). The parents chose Fortis. Her organs collapsing by the time she was placed in the PICU, Adya was put on life support: plasma transfusion, renal-replacement therapy, high-pressure ventilation. The last time her family saw her conscious was on the night of September 1. As she lay, strapped and unconscious, the only sign of change her parents saw was the daily SMS from the accounts department. “Sept 1st, Rs 48922...Sept 6th, Rs 700318...Sep 9th, Rs 1046420.”
Worried about her chances of recovery, the father started requesting an MRI scan on the fifth day of Adya’s admission. “On September 12, a committee of doctors told us that her condition was critical. My husband told them that he wasn’t going to pay any more money until they did an MRI and found out about the extent of damage to the brain,” said Deepti. “On the 13th, they finally did an MRI and told us that the brain was 70 to 80 per cent damaged.” It was up to the parents to decide now: they could let the hospital keep her on life support in the bleak hope of a recovery, or they could let her go by asking for the tubes to be taken off. The parents chose to seek a second opinion. On September 14, they took her case files to Gurgaon’s Medanta hospital, where they were given the same two options.
The family decided to take the child home. At 2am on September 15, Jayant signed a form confirming that he was taking his daughter home “against medical advice”. Against the entry asking him to articulate “the important outcomes/risks which may result on account of my action”, he scrawled a single input: “Death.” In the absence of any legal ground for discharge of patients on life support, the only way an Indian hospital will allow it is after the family has consented to their Leaving Against Medical Advice (LAMA). It’s not a release without responsibilities, however. As per LAMA guidelines set by the Indian Medical Association, a hospital must transfer a patient from life support to life support, a condition that includes arrangement of an appropriately equipped ambulance.
Fortis did not arrange for an ambulance while releasing Adya from their care; the family was asked to hire one from a recommended service provider. The family chose one that did not contain an ambu bag, a manual resuscitator used for ventilation. The parents told HT they knew their daughter would be dead once the doctors take off the tubes. After he had paid the outstanding bills, a process that took six hours, the father asked the Fortis management if he could “turn around the ambulance and get the baby readmitted to the hospital to get a death certificate, but this was refused”. Once she was transferred to the ambulance, “the doctor removed the ventilators and the pipe, waited for 2-3 minutes, and pronounced the baby dead and asked us to go,” the mother said. By the time they procured a “brought dead” certificate from Rockland Hospital, whose initial response was to deny it, the sun was out. At 9 am, when Adya’s body was placed on the floor of the family’s living room, her parents were determined to put the past two weeks behind them.
The big fight
But they couldn’t. As questions and counsel poured in from friends and well-wishers, the parents were forced to relive every second of their two weeks at Fortis. They were also struggling to comfort their other child, Adya’s twin sister, who felt confused and alienated. On October 6, Deepti found out that she was pregnant. She was forbidden stress by her doctor. On October 15, she lost the child. By now the parents were convinced that their lives had been ruined by Fortis. On November 16, a college friend of Jayant’s tweeted a scan of the 20-page bill Fortis had charged the Singhs. It was retweeted thousands of times overnight. The details made headlines for days: ?15 lakh bill for 15-day treatment, family billed for 660 syringes and 2,700 gloves, 1,700 per cent margin on consumables and medicines. By early December, the case had blown up into a battle between middle-class parents and private healthcare, exposing a number of wrongs but no clear villain.
“Now that the fight is on, I want to take it to the next level,” said Jayant, surrounded by stuffed animals — teddy bears, elephants, dogs, zebras — in the living room of his two-bedroom apartment. Since he took up the fight, he has made a series of allegations against the hospital. Other than “inflated bill”, “unreasonably prolonged” treatment, and breach of LAMA, Singh has accused the hospital of forging his and his wife’s signatures on consent forms and offering him a bribe to drop the charges (“a refund of Rs 10,37,889 lakh that I paid Fortis from my pocket — insurance covered the rest — and Rs 25 lakh in cash”). That’s not all. The Singhs have alleged that after confirming the prognosis of their daughter’s condition on September 14, the doctors advised them to “let the baby die in peace.” The question they would like answered is: “Would you still called it LAMA?”
Fortis responds
Asked for a response, the management at Fortis told HT, “We strongly deny any such allegations.” It’s not unusual, however, for doctors to make that “informal suggestion”, said Narottam Puri. “This conversation happens between doctors and families.” A doctor himself for the past 40 years, the 70-year-old said the community has never felt more besieged. “I feel insulted. I feel humiliated. People are calling us thieves, murderers.” He would like the world to understand that a doctor is as helpless as the family in a case like this. “Legally, we can’t let a patient under a ventilator go. What to do in a situation where there is a slim chance of survival or doubts about the quality of life? The law should allow the doctor to take off life support of a brain-dead patient.”
Could the doctors have let the family know about the extent of brain damage sooner? “When to do MRI is decided by a number of factors. If we had taken her off the ventilator and shoved her into an MRI machine in her earlier condition, she would have died of that shock.”
What about the breach of LAMA protocol? “ The law is unclear,” said Puri. “Theoretically, the hospitals bears vicarious responsibility until the patient is transferred to another facility; the ambulance becomes an extension of the hospital — but how can we control where the family will take the patient? Kahaan chhod ke aayein (Where do we leave the patient)? Earlier we used to provide ambulances, but in one such case, once the patient was transferred to the ambulance, the family said they wanted to be taken to their home in Agra — the vehicle didn’t even have the permission to drive out of Delhi!”
Puri said the hospital didn’t prolong Adya’s treatment to make money off her parents. “No hospital profits from keeping a patient longer. Fortis has one of the city’s 12 PICUs. There is a long waiting list. Our profits come from rotation of beds.” He said the treatment Adya received at Fortis was “second to none” and it comes at a cost. “ICU costs money. Ventilated patients cost a lakh a day. If you think we are looting you, go somewhere else.” The number of syringes and gloves used in the treatment of was “consistent with medical practices anywhere in the world,” said Bhavdeep Singh, CEO of Fortis Healthcare.
The hospital staff didn’t forge their signatures on the case files, either, he said, but only put in their names where required. Did one of his representatives offer the father a bribe to shut up? “We went to meet the father. He told me about his financial difficulties. I offered to set up an education fund for Adya’s twin totalling the amount he paid to Fortis. But he asked for more money. He wanted Rs 25 lakh. If we had intended to bribe him, we would have met him in a dark alley, not at a well-known hotel.”
Right and wrong
Who should you believe? The only investigation done so far is by a fact-finding panel set up by Haryana’s health department. In the report submitted to the Haryana government, the four-member team found Adya’s treatment “adequate” and the hospital’s usage of consumables “not injudicious”, but it criticized the hospital for suggesting LAMA and the parents for accepting it: “Half-hearted attempt by institute led to the ill-informed decision by father which led to this unfortunate incident”. The panel also found the “lack of ‘patient transfer to ambulance’ protocols and ‘patient transport in ambulance’ protocols evident.” Their forensic expert revealed that the said columns in consent forms hadn’t been filled with “The Name” of the parents, but signatures were done.”
On overpricing, the experts found that the “total bill was charged at a profit margin of 108 %”. No violation of Drug Price Control Order was observed, according to the report. However, it noted aberrations of a different kind. “Baby Adya was issued Meropenem Injection 1gm of two different brands with different MRPs with huge gap in price. The brand Merocrit Inj was found having MRP 3112.50 per unit but the other brand, Merolan Inj, was found with MRP 499 per unit.” In another such instance flagged by the report, “Fortis overcharged Rs 12,800 for 8 units of platelets in spite of knowing that they have to charge at Rs 400 per unit only.”
In an ICU, says Dr K Srinath Reddy, president of Public Health Foundation of India, “there are bound to be many expenses, but if they are clearly very high markups then that’s not acceptable. Doctors will say if you want quality, there will be cost, but part of what makes quality is cost optimisation.” He believes the parents would have been spared a lot of trouble if the doctors had communicated with them clearly. “Obviously, when a sick child is there, you try to save the child. But at what point should you reveal the extent of brain damage? Should you suggest a full-body plasma transplant after telling them there is no chance of recovery? A good panel of doctors should have formed a clear consensus and communicated it to the parents.”
However, he says, the essential question here is about the flaws of our healthcare system. “Emergency transport should be part and parcel of healthcare of a country. None of this would have happened if we had prepaid universal healthcare system.”
