Case Summary
Appellant: Ahmed Ihsan
Defendant: State (Ministry of Health)
Court: Supreme Court of the Maldives
Case no.: 2016/SC-A/05
Justice’s bench: Dr. Ahmed Abdulla Didi, Uz. Abdulla Areef, Uz. Adam Mohamed Abdulla.
Nature of dispute: Recovery of Damages (Medical Negligence).
Case registration date: 01 March 2016
Judgement date: 25 June 2019
Case appealed: Ahmed Ihsan v. Ministry of Health decided by the High Court of the Republic of Maldives under case no: 2009/HC-A/368.
Facts
On 5 July 2007, 3-year-old Aishath Iyan Ihsan (Patient), daughter of Ahmed Ihsan (Appellant), was admitted to Gaafu Dhaalu Faresmaathoda Health Centre with a fever. After 3 days of treatment, swelling developed in the Patient’s left hand, and she was advised to seek further care at Gaafu Dhaalu Thinadhoo Regional Hospital. Consequently, on 14 July 2007, she was taken to Gaafu Dhaalu Thinadhoo Regional Hospital for continued treatment.
On 14 July 2007, at Gaafu Dhaalu Thinadhoo Regional Hospital, the Patient was consulted by Dr. Gopan (General Medicine), who immediately admitted her and referred her to paediatrician Dr. Paval Bobko. Upon assessing the Patient’s left hand and reviewing blood test results, Dr. Bobko suspected the presence of an abscess beneath the skin. As such, the Patient was referred to Dr. Rudra Prasad, the hospital’s Consultant Surgeon.
Following discussions between the two doctors, additional tests were conducted to determine the cause of the swelling, revealing a bacterial infection. Based on these findings, Dr. Bobko prescribed gentamicin, an antibiotic known for treating both gram-positive and gram-negative bacterial infections which is also associated with severe side effects. Additionally, an Incision and Drainage procedure was ordered to remove any abscesses in the left hand. However, no abscess was drained during the procedure-only a blood-coloured fluid was drained.
After the surgery, she remained under observation and continued receiving gentamicin treatment.
On the morning of 17 July, the Patient reported difficulty hearing, prompting Dr. Bobko to examine her. Following the assessment, she was prescribed Waxsol, a medication used to treat earwax buildup, and the administration of gentamicin was discontinued. Despite this, her hearing difficulties persisted.
On 18 July 2007, as the Patient’s fever and swelling in her left arm persisted, another Incision and Drainage procedure was performed to check for a deep-seated abscess. However, no abscess was was found or drained. Following the procedure, her fever subsided, and the swelling began to decrease.
On 23 July, Dr. Bobko discharged the Patient from the hospital. Due to the absence of an Ear, Nose and Throat (ENT) speciality at the faculty, she was advised to seek further treatment for her hearing issues in Male’.
On 25 July, the patient was taken to Male’ and examined by Dr. Mauroof Hussain at Indira Gandhi Memorial Hospital. As the necessary tests were unavailable in the Maldives, Dr. Hussain recommended seeking treatment abroad.
On 04 August, they travelled to India for further evaluation. After consultation and testing, they were informed that the Patient suffered complete hearing loss and required cochlear implants.
After returning to Male’, the Patient was reavaluated by Dr. Hussain, who based on the diagnosis doctors in India, identified gentamicin as the probable cause of her hearing loss. Consequently, the Appellant filed a lawsuit against the Ministry of Health, seeking MVR 7,119,100 in damages. This amount accounted for the total cost of the surgery and rehabilitation, the recurring expenses for cochlear implant batteries and spare parts every six months for 35 years, the cost incurred during their stay in India for treatment, compensation for future losses due to the Patient’s disability, and damages for the psychological distress caused by her condition.
Case Timeline
Civil Court (Case no.: 523/MC/2008)
Based on the evidence presented, the Civil Court ruled that there was no basis to conclude that the Patient’s hearing loss resulted from Dr. Bobko’s negligence administration of gentamicin. Applying the Bolam Test-a standard used to determine whether a medical practitioner has met their duty of care-the court found that Dr. Bobko’s actions were consistent with what a reasonable doctor would have done in similar circumstances. As a result, the claim was dismissed.
High Court of the Republic of Maldives (Case no.: 2009/HC-A/368)
The Appellant appealed the case to the High Court, contending that the Civil Court’s decision contradicted both legal and Shari’ah standards. The Appellant argued that the Civil Court’s ruling was based on falsified medical reports and an incorrect application of the Bolam Test. Additionally, critical issues such as the failure to properly test the Patient and the Respondent’s documentation errors, were not adequately addressed. However, after considering the witness and expert testimonies, the High Court upheld Civil Court’s decision.
Supreme Court of the Maldives (Case no.: 2016/SC-A/05)
The Appellant subsequently appealed the case to the Supreme Court of the Maldives, arguing that the High Court’s decision was inconsistent with both legal and Shari’ah principles as:
- Forensic reports indicated alterations in medical documents, and witness accounts differed with respect to the timeline.
- There cannot be reliance on testimonies from the staff at Gaafu Dhaalu Thinadhoo Regional Hospital, who are allegedly responsible for the negligence.
- The High Court’s conclusion that genetic factors caused the hearing loss, following the administration of gentamicin, lacked supporting evidence.
Judgment
The Supreme Court of the Maldives ruled in favor of the Appellant and awarded MVR 7.1 million in damages.
The Court held that:
- Doctors have a responsibility to provide the highest standard of care and treatment, in accordance with “Good Medical Practice: A Code of Conduct for Doctors in the Maldives,” the “Regulations, Guidelines and Rules of Procedure” from the Maldives Medical and Dental Council, Article 50 of the Health Services Act, and Article 27 of the Health Care Professional Act. Article 35 of the Health Services Act mandates that health service providers ensure the highest standard of care. The Court held that omissive liability – where a medical professional fails to deliver the highest standard of care – applied in this case. While the Health Services Act and the Health Care Professional Act were not in effect at the time, the Court found that Article 68 of the Maldivian Constitution allowed for the incorporation of established norms and practices from developed countries.
- The Court emphasized that in medical negligence cases, the following must be established 1) malpractice, 2) damage, and 3) a causal relationship between the malpractice and the damage.
- The Court found that Dr. Bobko did not follow proper procedures in diagnosing the Patient before administering gentamicin, a powerful and dangerous drug. Key failures on their part included:
- Not testing the blood-colored fluid taken from the first incision and drainage procedure, violating “Good Medical Practice: A Code of Conduct for Doctors in Maldives” which mandates appropriate testing.
- Not explaining important details to the Appellant about the drug, including its side effects, dosage and administration timing and not documenting the same in the prescription.
- Not recording the weight of the Patient which could have led to administration of an incorrect dosage of gentamicin.
- Discrepancies in the testimonies. As Dr. Bobko and a Nurse stated that the issue was raised on 17 July. However, Dr. Prasad’s statement indicated that the issue was raised on 20 July.
- Testimonies suggested that some gentamcin should have been left over if administered as stated. The Defendant could not explain what happened to the unused gentamicin, with no residual mediation provided to the Patient as would typically be expected.
- Forensic analysis of the medical documents revealed alterations, rending the reports unreliable and inadmissible.
- The Defendant failed to provide any other explanation for the cause of the hearing loss.
Therefore, the Supreme Court of the Maldives held that Dr. Bobko’s failure to properly administer the gentamicin likely caused the hearing loss. As the parent organization of Thinadhoo Regional Hospital, the Ministry of Health was ordered to pay the damages.
Laws and Regulations cited in the Judgment
- Constitution of the Republic of Maldives (Article No.68) – DHIVEHI – ENGLISH
- Good Medical Practice: A Code of Conduct for Doctors in Maldives – ENGLISH
- Regulations, Guidelines and Rules of Procedure – ENGLISH
- Health Services Act (Act no. 29/2015) – DHIVEHI
- Health Care Professionals Act (Act no. 13/2015) – DHIVEHI
Editorial Team
Yafis Ahmed
Author
