doctor's liability to care child.

1. MANAGEMENT OF NEONATAL
INTENSIVE CARE UNIT (NICU)
&
ACCOUNTABILITY UNDER THE
L A W
Dr. Rajneesh Kumar Patel
Associate Professor
Faculty
of Law, B.H.U.

2. WHAT IS THE
NEONATAL INTENSIVE CARE UNIT (N.I.C.U.)
?
The NICU is life saving unit of the Hospital, any newly
born babies who needs a very special type of care or
intensive medical attention and admitted into a special area
of the hospital called the Neonatal Intensive Care Unit
(NICU). In this unit one can find advanced technology and
trained healthcare professionals to provide specialized care
to the babies.

3. WHICH BABIES NEED N.I.C.U. ?
 generally, premature babies requirs
NICU or low birth weight babies or
any other medical condition which
requires special care and attentions by
medical professionals.

4. Reasons for NICU
◦ If mother is younger than 16 or older than 40 years, or
◦ Alcohol user, or
◦ Diabetic patient, or
◦ Hypertension, or
◦ any Bleeding, or
◦ Suffering from sexually transmitted diseases.
◦ In case of multiple pregnancy, or
◦ Inadequate amniotic fluid.

5. ◦ In case of changes in organ systems due to lack of
oxygen.
◦ Breech delivery presentation or other abnormal
presentation.
◦ The Baby's First Stool Passed during pregnancy into the
Amniotic Fluid, known as Meconium.
◦ Cord around the Baby's Neck.

6. ◦ Birth at Gestational Age less than 37 Weeks or More than
42 Weeks
◦ Birth weight less than 2,500 Grams (5 Pounds, 8 Ounces)
or Over 4,000 Grams (8 Pounds, 13 Ounces)
◦ Small for Gestational Age.
◦ Medication or Resuscitation in the Delivery Room
◦ Birth Defects.
◦ Respiratory Distress including Rapid Breathing, Grunting,
or Stopping Breathing.
◦ Infection .
◦ Hypoglycemia (Low Blood Sugar)

7. WHO WILL CARE FOR BABY IN THE NICU
 It is a team work and this groups includes, Neonatologist ,
Neonatal nurses and other staffs.
 Member of this group should be a man of special training,
skill, and knowledge in the care of newborn babies.
 In advance system the members of the NICU team are also
working together with parents to develop a plan of care for
high-risk newborns.

8. STRUCTURE OF N.I.C.U.
This unit should be well organized and advance unit in
comparison with other wings of the hospital. It should
contain all necessary equipments and proper facilities.
It includes adequate number of following equipments:
 Resuscitation set.
 Open care system.
 Incubators.
 Infusion pumps.
 Positive pressure ventilators.
 Oxygen hoods, oxygen analyzers.
 Heart rate – apnea monitors with scope.
 Phototherapy unit.

9. Cont………
 Electronic Weighting Scale.
 Pulse Oxymeters.
 End tidal CO2 monitor .
 Transcutaneous PO2 & PCO2.
 Noninvasive B.P. monitors.
 Invasive B.P. monitors.
 ECG monitor with defibrillator.
 Intra cranial pressure monitor.
 Portable radiographic machine.
 Portable ultrasound machine.
 Blood gas analyzer.

10. Cont………
•IV Catheters
•IV Sets
•Micro Burette Sets
•Bacterial Filters
•Feeding Tubes
•Endotracheal Tubes
•Suction Catheters
•Three-way Stopcocks
•Extension Tubing
•Umbilical Arterial And Venous Catheters
•Syringes, Needles
•Trocar And Cannula

11. ESTABLISHMENT AND CONDITION OF
N.I.C.U.
The N.I.C.U. should be established closer to the labour
rooms and operation theatre.
 There should be proper sunlight and ventilation of fresh air.
There should be proper space for concerning of patient,
keeping the essential equipment and for movement of
doctors, nurses, other staff.

12. Cont………………
 There should be proper arrangement of uniform and
shadow-free lighting .
 The temperature should be adequate inside the unit.
 The unit should also have an intercom & a direct outside
telephone line .
 There should be round-the-clock power back up including
provision of UPS system.

13. NURSES
 Nurse : patient ratio of 1:1 must be maintained 24
hours.
 In addition to basic nursing, staff nurse need to be
trained in handling equipment, use of ventilators and
initiation of life-support like use of bag and mask
resuscitation, endotracheal intubations, arterial
sampling and so-on.
 The staff must have a minimum of 3 years work
experience in special care neonatal unit.

14. STAFF
 A full time neonatologist. (One neonatal physician is
required for every 6-10 patients)
 At least two resident doctors should be present in the unit
round-the-clock.
 Pediatric Surgeon, Pediatric Pathologist and Respiratory
Therapist, Laboratory Technician, Public Health Nurse or
Social Worker, Biomedical Engineer are very much
essential persons in establishment of a admirable quality of
NICU.

15. Right to considerate and respectful care.
Right to information on diagnosis, treatment and medicines.
Right to obtain all the relevant information about the
professionals involved in the patient care.
Right to expect that all the communications and records
pertaining to his/her case be treated as confidential
Right to every consideration of his/her privacy concerning
his/her medical care programme.
Right to expect prompt treatment in an emergency
Right to refuse to participate in human experimentation,
research, project affecting his/her care or treatment.

16. GENERAL DUTIES OF MEDICO PERSONALS
Every doctor has some basic things to do :
1. He must listen to the patient and take proper history.
2. Examine him carefully. He must attend him or her
personally and give diligent care.
3. He must explain the relevant facts related to the illness.
4.He must advice proper medicines.
5.He must have average, recent knowledge and equipments in
possession, as per their specialty.
6.He must be able to foresee the complications and refer the
patient at proper time.
7.He must also maintain a proper record of their patients.

17. RESULT OF FAILURE
There are three types of law which may be applicable to the
medical staff :
1.Statutory law, which are creation of legislators.
2.Regulatory law or administrative law which are created by
administrative bodies and it consists of rules and regulations.
3.Judicial law , which are the decisions of mainly High Courts
or Apex Court of India.

18. STATUTORY LAWS
1. INDIAN CONTRACT ACT, 1872.
2. INDIAN PENAL CODE, 1860.
3. CONSUMER PROTECTION ACT,1986.
4. INDIAN MEDICAL COUNCIL ACT,1956.
5. PRE- NATAL DIAGNOSTIC ACT, 1994.

19. REGULATORY LAWS
•Indian Medical Council (Professional Conduct, Etiquette and
Ethics) Regulations, 2002
•Hippocratic Oath.
•Declaration of Geneva.
•Declaration of Helsinki.
•International Code of Medical Ethics.
•Govt. of India Guidelines for Sterilization.

20. JUDICIAL LAW
 Decision of High Courts and Supreme Court.

21. REMEDIES AVAILABLE UNDER THE INDIAN
LAW IN CASE OF MEDICAL NEGLIGENCE
 (1) CIVIL SUIT BEFORE CIVIL COURT.
 (2) CIVIL SUIT BEFORE CONSUMER
COURT.
 (3) COMPLAINT BEFORE MEDICAL
COUNCIL.
 (4) CASE BEFORE CRIMINAL COURT.

22. WHEN DOES ACCOUNTABILITY
ARISE?
 It is well known that a doctor owes a duty of care to his
patient. This duty can either be a contractual duty or a duty
arising out of tort or civil law. This may be a criminal
breach of duty for which penal action may be taken. In
some cases, however, though a doctor-patient relationship
is not established, the courts have imposed a duty upon the
doctor. In the words of the Supreme Court “every doctor, at
the governmental hospital or elsewhere, has a professional
obligation to extend his services with due expertise for
protecting life” (Parmanand Katra vs. Union of India).

23. LIABILITY UNDER CIVIL LAWS
1. Under Contract Act :
According to Sec. 70 of Indian Contract Act, when a patient
goes to a doctor for medical treatment, he enters into an
implied contract with the doctor that he will use reasonable
professional skill and care in treating the patient. If the doctor
doesn’t give complete or proper treatment or fail to fulfill this
contractual obligation the patient can claim damage under Sec.
73 of the Act. Similarly, if the patient doesn’t pay the fees,
doctors can file a civil suit. Doctors can take advances or
deposits before starting treatment, but they can’t keep the
patient in confinement on the ground of nonpayment of fees.

24. LIABILITY UNDER CIVIL LAWS
2 . Under Tort Law :
If a doctor does not take reasonable degree of
care, which he is required to take under law
and thereby causes injury to his patient, he
can be sued under the law of Tort.

25. LIABILITY UNDER CIVIL LAWS
3. Under C. P. Act:
After 1995, the medical profession comes within the ambit
of a 'service' as defined in the Consumer Protection Act,
1986.This defined the relationship between patients and
medical professionals as contractual. Patients who had
sustained injuries in the course of treatment could now sue
doctors in 'procedure-free' consumer protection courts for
compensation, even though services rendered by medical
practitioners are of a personal nature they cannot be treated
as contracts of personal service They are contracts for
service, under which a doctor too can be sued….. Indian
Medical Association v VP Shantha.

26. LIABILITY UNDER CRIMINAL LAW
If negligence is so blatant then it invites criminal proceedingsand
on proof of negligence penal action may be taken against
doctors. A doctor can be punished under Section 304A of the
Indian Penal Code for causing death by a rash or negligent act,
for example : where death of a patient is caused during operation
by a doctor not qualified to operate. Some of the common
sections of Indian Penal Code which are applicable to doctors
include: Sec. 312-316 related to causing abortions or miscarriage
without proper consent; Sec. 319-322 deals with causing
grievous hurt, or disfigurement endangering the life; Sec. 340-
342 related to wrongful confinement of patient; and Sec. 499 is
related to defamation.

27. LIABILITY UNDER MEDICAL COUNCIL
ACT
 This Act provide for the constitution of a
Medical Council of India. Under section 33 this
council can set norms to regulate the conduct
and behaviour for the medical practitioners.
 The norms set by the council are mandatory
and also followed by the State Medical
Council.

28. WHAT IS THE DUTY OWED?
 The duty owed by a doctor towards his patient, in the words
of the Supreme Court is to “bring to his task a reasonable
degree of skill and knowledge” and to exercise “a
reasonable degree of care” (Laxman vs. Trimback).
 The doctor, in other words, does not have to adhere to the
highest or sink to the lowest degree of care and competence
in the light of the circumstance. A doctor, therefore, does
not have to ensure that every patient who comes to him is
cured. He has to only ensure that he confers a reasonable
degree of care and competence.

29. MEDICAL NEGLIGENCE
 Under Indian law; medical negligence may be
two types, civil wrong or criminal offence. For
civil wrong compensation may be awarded
and for criminal offence a doctor can be
imprisoned.

30. NEGLIGENCE
 In its general sense negligence means lack of
proper care and attention or it is a carless
behaviour.
 It contain three things:
1. A legal duty.
2. Breach of this duty.
3. Damage caused by breach.

31. WHAT IS MEDICAL NEGLIGENCE
There are three essential of medical negligence:
 The existence of a duty to take care, which is
owed by the doctor to the complainant.
 The failure to attain that standard of care,
prescribed by the law or administrative bodies or
by judiciary.
 Damage, which is both causally connected with
such breach and recognized by the law, has been
suffered by the complainant.

32. The court’s view:
 BOLAM VS. FRIERN HOSPITAL MANAGEMENT
COMMITTEE the Queen’s Bench Division of the British
Court held that:
 A doctor is not guilty of negligence if he has acted in
accordance with a practice accepted as proper by a
responsible body of medical men skilled in that particular
art.

33. Cont………
 Jacob Mathew vs. State of Punjab :
The standard of care, when assessing the practice as adopted is judged
in the light of the knowledge available at the time (of the incident),
and not at the date of trial. When the charge of negligence arises out
of a failure to use some particular equipment, the charge would fail if
the equipment was not generally available at that point of time on
which it is suggested as should have been used. So long as a doctor
follows a practice acceptable to the medical profession of that day, he
cannot be held liable for negligence merely because a better
alternative course or method of treatment was also available or simply
because a more skilled doctor would not have chosen to follow or
resort to that practice or procedure which the accused followed.

34. Cont…….
Therefore, a professional may be held liable for
negligence when
 a) He was not possessed of the essential skill
which he professed to have possessed; [and/ or]
 b) He did not exercise, with reasonable
competence in the given case, the skill, which he
did possess.

35. Dr. Suresh Gupta vs. Govt. of Delhi
 a medical practitioner cannot be held punishable for
every mishap or death during medical treatment. No
criminal liability should be attached where a
patient’s death results from error of judgment or an
accident. Mere inadvertence or some degree of want
of adequate care and caution might create civil
liability but would not suffice to hold him criminally
liable. The degree of medical negligence must be
such that it shows complete apathy for the life and
safety of the patient as to amount to a crime against
the state.

36. Dr. Anand R. Nerkar vs. Smt Rahimbi
Shaikh Madar
In this case the Supreme Court laid down following guidelines for prosecuting
doctors:
 1. A private criminal complaint should not be entertained unless the
complainant has produced prima facie evidence in the court in the form of a
credible opinion given by another competent doctor to support the charge of
rashness or negligence.
 2. The investigating officer, before proceeding against a doctor, should obtain
an independent medical opinion preferably from a doctor in government
service qualified in that branch of medical practice.
 3. The accused doctor should not be arrested in a routine manner unless his
arrest is necessary for furthering investigation or for collecting evidence or
unless the investigating officer feels satisfied that the doctor will escape.
However ……………………………..

37. CONCLUSION
In ancient days, medical profession was considered to be a
noble field. The patient’s faith and trust in doctors was so
much that a doctor was equated to lord Vishnu. Gradually, this
relationship is turning into a love and hate phenomenon. In
this era, the focus of medical profession is progressing from a
noble one to a commercial one. The cost of medical education,
equipments, construction of clinics and hospitals are to some
extent responsible for the commercial approach on part of
doctors. Patients now are also more interested in facilities and
good looking hospital rather then quality of care and
competency of doctors. In this scenario, litigations related to
medical practice are on the rise.

38. HOW TO AVOID COURTS?
 If you wish to avoid such situation, attend all patients
personally and carefully. Behave humanely, avoid rough,
rude or inhuman behavior with the patients or their
relatives. Communicate with the patient and take proper
consent after explaining the condition. Documents related
to a particular case should be maintained properly.
Be efficient and have proper expert opinion especially in
serious illnesses. Keep your knowledge updated and keep
latest instruments , if possible.

39. MESSAGE TO MEDICO-PERSON
 PLEASE DOCTORS, think twice litigations against
medical practitioners are rising as the relationship between
doctor and patient is deteriorating.
 Don’t forget your duties with your rights as a medical
practitioner.
 Take a valid consent and maintain perfect records of your
patients.
 Don't get upset if there is case against you in consumer
forum.
 Have a respect for law, God and of course for human
beings.

40. THANK
YOU