Illegible prescription could lead to medical negligence and deficiency of service Misinterpretation by the pharmacist Wrongful dispensing of medicines by pharmacist National Consumer Disputes Redressal Commission Delhi State Consumer Disputes Redressal Commission Consumer court Medical negligence Medical negligence in nephrology Bad handwriting in prescription

1. Illegible prescription
constitutes deficiency in
service: State Commission to
reopen hearing
Dr. Arun Sharma

2. Case facts
• Wife of a deceased kidney patient filed a complaint before the Delhi State
Consumer Disputes Redressal Commission alleging medical negligence
• She alleged that a senior nephrologist from a reputed hospital in Delhi
prescribed tab ‘Ketosteril’ to her husband
• However, the pharmacist from the same hospital’s pharmacy wrongly
dispensed the tab ‘Ketorol-DT’
• Ketosteril contains amino acids, partly in form of there corresponding-
ketoanalogues. In combination with a protein-restricted diet Ketosteril is an
excellent tool to treat Chronic Kidney Disease in the predialysis period*
*https://www.fresenius-kabi.com/in/products/ketosteril

3. A note of ketorolac
• Ketorol (Ketorolac) is a nonsteroidal anti-inflammatory drug (NSAID)
• It is indicated for the short-term (up to 5 days in adults), management
of moderately severe acute pain that requires analgesia at the opioid
level and only as continuation treatment following IV or IM dosing of
ketorolac tromethamine, if necessary
• The total combined duration of use of ketorolac tromethamine should
not exceed 5 days
• Ketorol is CONTRAINDICATED in patients with advanced renal
impairment and in patients at risk for renal failure due to volume
depletion
USFDA Prescribing Information

4. Case facts
• The complainant stated that because of wrong medicine, her husband
suffered several complications that resulted into death
• She alleged deficiency in service and medical negligence against the
doctor, hospital, and the pharmacist
• The main contention in the case was whether illegible writing of the
doctor resulted in pharmacist issuing him medicine contrary to the one
prescribed

5. • The whole controversy in the case hinges on the point whether illegible
writing of the doctor resulted in pharmacist issuing him medicine
contrary to the one prescribed
• On a careful consideration of the matter it is noticed that this is not a
consumer dispute.
• It is settled a position of law that a case where trial is required and
examination and cross examination of evidence are required to be led
into cannot be adjudicated under the provisions of Consumer Dispute
Act, 1986

6. State Commission returned the complaint
• The State Commission returned the complaint with the direction to
file before the appropriate authority for adjudication
• It relied upon the decision in the matter of Bright Transport
Company Ltd. vs. Sangli Sehkari Bank Ltd. II(2012) CPJ 151 (NC),
in which it was held that complaints which are based on allegations of
fraud, forgery, etc. and trial of which would require voluminous
evidence and consideration are not to be entertained by this
Commission

7. NCDRC did not agree with State Commission
• NCDRC observed that this is a case of alleged medical negligence
(resulting in death), alleged deficiency in service, which can be
adjudged in the normal wont under the Consumer Protection Act, 1986
• National Commission did not find any element of voluminous evidence
and consideration, as may make the adjudication of this case
unfeasible or proscribed in consumer for a
• It disagreed with the State Commission’s observation that “this is not
a consumer dispute.”
• It is decidedly a “complaint” within the meaning of section 2(1) (c) of
the Act 1986 and would convert into a “consumer dispute” within the
meaning of section 2(1) (e) if the opposite parties dispute or deny the
allegations contained in the complaint

8. Order
• National Commission did not comment on the merit of the case to avoid
coloring the vision of the State Commission
• The order passed by the State Commission was set aside and the
matter remanded back to the State Commission
• The State Commission was requested to adjudicate on the complaint
under the Act 1986

9. Why is this case significant?
• The question as to what is a consumer complaint/dispute was settled in
this case
• What constituted medical negligence in this case is debatable until
finally decided by the court
• Illegible handwriting of the doctor or misinterpretation by the
pharmacist, who is to be blamed for the deficiency in service?

10. Based on:
Case before the NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION
FIRST APPEAL NO. 1062 OF 2018
Reference:
http://cms.nic.in/ncdrcusersWeb/GetJudgement.do?method=GetJudgement&caseidin=0%2F0%2FFA%2F1062%2F2018&dtofhearing=2018-
10-05
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