DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, Civil Station, Palakkad – 678001, Kerala Dated this the 22nd day of October, 2010 Present: Smt.Seena.H, President Smt.Preetha.G.Nair, Member Smt.Bhanumathi.A.K, Member CC No.128/2005 Arathi, D/o.Sasikumar, Minor, Represented by next friend father Sasikumar, 32/260, Prathibha, Vennakkara, Noorani.P.O, Palakkad. - Complainant (By Adv.John John) Vs 1. Dr.S.Prakash Nayar, Thankam Hospital of PMRC, West Yakkara.P.O, Palakkad. (By Adv.V.K.Venugopal) 2. The Managing Director, Thankam Hospital of PMRC, West Yakkara.P.O, Palakkad. - Opposite parties. (By Adv.C.Madhavan Kutty) O R D E R By Smt.Seena.H, President Case of the complainant: Complainant is a minor and is represented by her father. Complainant is alleging medical negligence against the opposite parties in providing treatment to complainant following a fracture. On 16/04/2005, complainant met with an accident by falling from the wardrobe step having a height of about 3 ½ feet and sustained injury on the left forearm. She was immediately brought to Thankam Hospital and was admitted there. She was attended by the 1st opposite party. Complainant was taken to the operation theatre and plaster cast was applied for the reason that she sustained fracture shaftulna. By night complainant was not able to move her left fingers and the hand became slight bluish in colour and the warmth of the left hand was minimum. On 17/04/2005, as the 1st opposite party Doctor was not available, the duty Doctor examined the complainant and advised some exercises. On the next day 1st opposite party cut and removed part of the plaster and reapplied plaster cast and discharged the patient with the advise to consult him on the 15th day. On 19/04/2005 & 20/04/2005, the fingers developed swelling. On 21/04/2005 blisters were found on the left wrist and she was taken to the hospital. 1st opposite party was not available. The duty doctor and Nursing Superintendent cut and removed 3 inches of the plaster cast and sent back the complainant. She suffered high fever in the night of 21/04/2005 and was taken to the hospital on 22/04/2005. Doctors at 2nd opposite party hospital removed the entire plaster cast and found that the entire arm was having dark colour and skin of major portion was found to have been peeled off. Doctors of 2nd opposite party hospital contacted the Doctors at R.V.Clinic, Palakkad. Complainant was immediately taken to R.V.Clinic. The Doctors who examined there opined that part of the arm is dead and suggested amputation. On an enquiry made they revealed that the negligence at the time of application of plaster cast has caused the complication. Complainant was taken to Ganga Hospital on the same day itself. On examination, Doctors at Ganga Hospital found that the ’skin over left forearm and dorsum of hand blackish and discoloured, swelling present distal to elbow(left) no sensation below elbow(left), no active movements of fingers, radial and ulnar pulse not felt. Their treatment consideration was as follows. “The left forearm has suffered circumferential skin loss of both extensor and flexor group of muscle. The hand itself is precariously viable”. Complainant was initially treated as inpatient in Ganga Hospital for 68 days and was discharged on 29/06/2005. The detailed line of treatment provided to the complainant as narrated by the complainant as follows: Patient underwent six courses of treatment. On 03/05/05: Under GA and TQ control, full thickness necrosis over left forearm was excised, almost there is circumferential loss of skin in whole of the forearm except 1-2 cm of skin bridge intact over extensor aspect from wrist to elbow with epidermal loss of intact skin bridge. After excision of skin the muscle of flexor compartment were found discoloured and partially devitalised. Haemostasis secured. Ortho opinion taken for the bone fixation, and it was advised that as the wound is infected and bone or fracture site is not exposed, it is better to avoid bone fixation. Then wound was dressed and above elbow slab applied. On 7/05/05: Under neurovascular bundle, median nerve isolated and all the muscles flexor carpiulnaris. Flexor digitorum profundus, flexor digitorum superficialis, pronator quadratus flexor pollicis longus debrided. Later when tourniquet was deflated, bleeders cauterised, good capillary filling observed in all fingers. The exposed median nerve covered with collagen(neosprin) and wrist kept in volar flexion. Then POP applied in volar flexion. On 9/5/05: Under GA, left forearm, wound was debrided, washed with saline and abdominal flap was planned to cover the defect over flexor aspect of forearm with exposed median nerve and tendons. Medially based abdominal flap was planned over left side of abdomen based on paraumbilical perforator and hypogastric artery. Pattern made on lint piece cloth and marking done over abdomen. Incision made over the marked side, abdominal flap raised and inserted over forearm defect from wrist to elbow at radial border. Donor site covered with SSG fixed with ethilon 4-0. Graft taken from right thigh. Dressing applied. Forearm immobilized with plaster strapping to abdomen in adducted position at shoulder joint. On 9/06/05: Under GA 1/3rd of the flap on both edges were divided completely and sutured with 3-0 ethilon. On 17/06/05: Under SA, abdominal flap was divided, donor site was sutured primarily after achieving hemostasis with Vicryl 4-0 and ethilon 4-0 in two layers. Residual raw area over donor site will need SSG later on. Forearm wound was debrided, excess granulation tissue was excised. There was exposed radius in distal forearm and in proximal part ulna was exposed with fracture site. About 4cm of ulna was excised and fracture of ulna was rounded off to prevent injury to median nerve which was present nearby. Wounds margins were freshened and the wound exposing radius bone distally and ulna proximally was closed primarily. The ulna bone and raidus bone was exposed because of necrosis of superficial skin and devitalized muscle nearby. The exposed ulna was necrosed and dead hence decision was taken to excise a part of it. The whole median nerve which was salvaged in previous surgery was intact and adherent to bed and has become vascularised. So it is expected that some recovery of function in median nerve territory will come. After freshening the skin margin of flap, inset was given, suturing done with vicryl 4-0 and ethilon 4-0 in layers over a drain. Dressing and above elbow slab applied. Again she was admitted on 17/08/2005 and the following treatment was given. On 19/8/05: The sinuses on the ulnar border of forearm were debrided. The tracts were extending to the common unhealthy bone, so whole tract and the unhealthy skin and soft tissue was excised. The bone was retained in position. Then the pattern of the defect was taken and an inferiorly based flap measuring 12 x 10 cm was raised. The flap was based on inferior epigastris vessels. The raw area created at the donor site was covered with SSG harvested from the left thigh. Tie over dressing was given. The flap was inset on the forearm and dressing was done and limb was immobilised with strapping. Complainant was discharged on 29/08/2005. Condition at discharge as opined by the Doctor is that “flap will be delayed and divided. She will later need surgery for flexon replacement bone grafts. On 9/09/2005, again complainant was admitted and the line of treatment is as follows. On 10/9/05: Under LA with sedation the medial half of the base of abdominal flap was devided. Haemostasis achieved and skin sutured back with 4-0 ethilon. Dressing done. On 16/9/05: Under GA the flap was divided and the wound closed on both sides with 5-0 ethilon. The condition at discharge was that ’flap is healthy, donor area suture line is clean. On 12/12/2005, she was again admitted in the hospital. On 15/12/2005, she again underwent an operation which is detailed below. On 15/12/05: Under general anaesthesia and aseptic precaution, two wire were passed through the proximal ulna and two through the metacarpal. Distraction system connected and distraction checked. Pin dressing done. The condition at the time of discharge is that Umex fixator of (left) forearm in situ. On 26/12/2005, complainant was again admitted of pintract infection with loosening of the frame present suggestive of infective loosening. Under general anaesthesia the pins at Proximal ulna found to be loose and these pins were changed and frame completed. Her condition at the time of discharge was afebrile. Distal capillary filling normal. On 14/03/06 the complainant was again admitted for removal of external fixture. The treatment given was: Under general anaesthesia the Joshi’s external fixature over the left upper limb removed and above elbow cast applied. Condition at the time of discharge: left above elbow cast insitu. On 12/6/06 complainant was again admitted in the hospital for a thorough check up and was discharged on 14/6/06. On 21/8/06, complainant was again admitted in the hospital for Micro Vascular Free Fibula Transfer for left fore-arm reconstruction. The treatment given are as follows: On 24/8/06: The patient has well settled flaps over left fore-arm. There is significant bone loss in both radius and ulna. The plan was to bridge the proximal ulna to distal radius but on exploration we found that there was no bone stock available in the distal radius hence the plan was changaed to bridge ulna to ulna. The bone gap was 6 cm. A 10 cm free fibula was harvested from left leg. The peroneal pedicle was dissected down till it entered the bone. The distal fibular and was slotted into the distal ulnar stump. Proximally the fibula was fixed to the ulnar proximal end with a 4 hole plate. The pedicle was brought antero medially. The anastomosis was carried out end to end to a branch of ulna and its vanae communition under microscope with 10’ 0” ethilon. There was good bleeding found from the periosteal surface to fibula. The second vein was clipped. The skin flaps were closed in layers and a above elbow slab was given. Condition at the time of discharge wound healed well. Check X-ray shows bone graft position. On 16/4/07 complainant was again admitted in the hospital for further treatment and operation. She was discharge on 23/4/07. The treatment given are: On 20/4/07: Under general anaesthesia exploration of left volar aspect of wrist was done by an inverted ’L’ shaped incision. Medium nerves and ulnar nerve were isolated. Flexor tendons to 2, 3, 4, 5th finger were found and tied together. Exploration of left elbow was done by ’L’ shaped incision. Brachial artery, vein, biceps tendon were found. Part of the biceps tendon was cut and kept for flexor reconstruction. 30 cm sural nerve was harvested from right leg using standard lateral incision. It was divided into two 15 cm parts. Multiple transverse incision were given on the lateral aspect of right thigh for harvesting fascia lata of 15cm using Endoscopy tuned harvest, secondary repair of median nerve was done using 15 cm sural (reversed) nerve graft from elbow to wrist. The tunnel for all these nerve grafts were made subcutaneous in fore-arm on the distally ulna nerve at the distal fore-arm recuitised with sural nerve graft connected proximally to median nerve at elbow level ulnar aspect in respect to little and ring finger. Flexor tendon reconstruction was done by extending biceps tendon to flexor tendons of 2, 3, 4, 5th fingers using fascial lata, keeping elbow in extension. Haemostasis achieved. Wound in right leg, right thigh, left elbow, wrist were closed in layers with 3-0 monocryl for leg and thigh, 3-0 ethilon for elbow and wrist. Above elbow slab applied. Condition at the time of discharge: Dressing changed-wounds clean. Above elbow slab in position on left upper limb. Jubipress on the right lower limb. According to complainant, all these complications and the very serious medical situation arose due to the negligence of the opposite parties. Hence the complaint. Complainant prays a total amount of Rs.19,89,000/- with interest as compensation. 1st and 2nd opposite parties filed separate versions. According to 1st opposite party, the patient was brought to the 2nd opposite party hospital on 16/04/2005 with complaint of pain, swelling and deformity of left forearm following fall from a height at home. After clinical and radiological examination 1st opposite party diagnosed fracture shaft of ulna with displacement. After pre-anesthetic check up and assessment, she was taken to operation theatre for close reduction above elbow POP immobilization and the same was done with utmost care and caution. Same day night she was seen by duty RMO, she had no complaint and her general condition was stable as per Duty Doctor’s report. Next day patients relatives requested discharge since there was no problem. The duty Doctor asked them to wait till the 1st opposite party saw them, but they insisted discharge saying that they will review with the 1st opposite party on Monday. On 18th April, 2005, the patient reported with pain and swelling of the fingers. On examination it was found that the fingers were swollen and extensive movements of fingers were painful. Radial pulse was felt well. Suspecting the possibility of compartment syndrome, 1st opposite party split the POP cast completely open from elbow to wrist and was left wide open. The gap was covered with single POP bandage. According to 1st opposite party patient was not willing for admission as they stay near by even though admission was advised by opposite party No.1. They were told to report in case of increase in pain or swelling of fingers. Patient was adviced to do active movement of fingers and to keep limb elevated. It is stated that contrary to medical advice and to what was promised from the patients side, they did not report on 19th or 20th of April, 2005. They turned up only on 21st April with swelling of fingers and fever. 1st opposite party submits that he was out of station at that time. Complainant was seen by casualty duty Doctor who advised admission but patient’s relatives were unwilling for admission. She was prescribed antibiotics and analgesics and the POP was again cut open by RMO. On 22nd April, patient was brought to the hospital with complaint of fever and bluish discolouration of fingers. The patient was shown to surgeon by duty RMO. The surgeon examined the patient and her POP was completely removed. She was then sent for orthopaedic consultation in the 2nd opposite parties ambulance to a near by Orthpaedic centre, R.V.Clinic. Doctors at R.V.Clinic advised admission and started treatment. But the parents of the complainant took her to Ganga Hospital, Coimbatore. 1st opposite party submits that the complainant did not have any difficulty or problems in the night of 16/04/2005 as alleged in the complaint. He also denies the allegation that he was not available on 17/04/2005. 1st opposite party further submits that he has not advised for discharge with advise to consult on the 15th day. He again advised admission on 20/04/2005 which was also turned down by the complainant’s parents. So it was advised to review immediately if she developed increase in pain and swelling. According to opposite party 1, the act of the parents of the complainant in not bringing the patient to the hospital in time has resulted in these complication. The problems developed due to compartment syndrome is a known and accepted complication after application of POP caste. The swelling of the forearm due to oedema underneath the plaster cast can result in compromise of vascular supply resulting in compartment syndrome. According to 1st opposite party, complications could have been avoided if the patient was brought back to the hospital immediately on seeing the pain and swelling. According to 1st opposite party whenever the complainant was brought to the hospital, she was given appropriate treatment also and there is no negligence on the part of opposite party 1. 2nd opposite party filed version in tune with that of 1st opposite party. The only point of difference in the 2nd opposite party’s version is that contrary to the version of 1st opposite party, it is stated that on 18/04/2005 the patient was discharged. It is not specifically stated that the complainant was discharged at their own request. It is also stated that when the patient reported on 21/04/2005, with swelling of fingers and fever, 1st opposite party was out of station to attend a conference in Chennai. It is submitted on behalf of 2nd opposite party that the patient was treated strictly adhering to the medical ethics and standard the situation warranted. It is the negligence on the part of the complainant in not adhering to the advice of the opposite parties regarding admission and prompt reporting on the prescribed date that led to the complication and hence opposite parties are no way liable. Evidence adduced consists of Exts.A1 to A29 marked on the side of complainant and Exts.B1 to B3 marked on the side of opposite parties. Dr.Raja Sabapathy was examined as PW1, Dr.Rajasekharan was examined as PW2 and Shri.Sasikumar was examined as PW3. 1st opposite party filed argument notes. Complainant has not filed any argument notes. Heard both parties. Now the issues that arise for our consideration are: 1. Whether there is any deficiency in service on the part of opposite parties? 2. If so what is the relief and cost complainant is entitled to? Issue No.1: Perusing the file we find that the allegation raised by the complainant is as follows: That the failure on the part of the opposite parties in not cutting open the POP plaster cast in time has led to the complications as stated in the complaint. That the advice of 1st opposite party for doing exercise has also added to the above complications. That the reference to R.V.Clinic by the opposite parties is not for any further treatment as contented but for amputation. The stand of opposite parties with regard to the allegations of complainant is as follows: According to 1st opposite party even though the duty RMO adviced admission on 17/04/2005 and requested the patient to wait till 1st opposite party saw them, the complainant’s parents were not willing for the same. Again when the complainant reported on 18/04/2005 with pain and swelling of fingers, suspecting the possibility of compartment syndrome, POP cast was completely opened from elbow to wrist and the gap was covered with single POP bandage. On that day the patient was not willing for admission even though adviced. Patient was told to report in case of increase in pain or swelling of fingers and was also adviced active movement of fingers and to keep limb elevated. That contrary to medical advice, complainant did not report on 19th and 20th. They turned up only on 21st with swelling of fingers and fever. That 1st opposite party was out of station on that day and casualty Doctor adviced admission. But complainant was not willing. Again POP was cut open and antibiotics were prescribed. That again on 22nd, patient was brought with complaint of fever and bluish discolouration of fingers. The patient was shown to surgeon by duty RMO and POP was completely removed. She was sent for orthopaedic consultation to a nearby orthopaedic centre. There also it is stated by opposite party that complainant parents got discharged against the medical advice for admission. The sum of the contentions of the opposite parties is such that all the complications developed is due to the non adherence of medical advice tendered by the opposite parties. As per the contentions of opposite party No.1 admission was adviced on 17th, 18th and 21st. But complainant was unwilling for admission. Going through the evidence with regard to the above contentions, we find that the version of 1st opposite party Doctor and 2nd opposite party hospital itself is contradictory. According to 1st opposite party, the patient was admitted on 16th and as there was no problem she was discharged the next day. It is also submitted that the patient was asked to wait till 1st opposite party saw her, but complainant did not wait. The version of 2nd opposite party in this respect is in tune with that of the complainant and Ext.A21 the discharge summary which shows that the complainant was admitted on 16th and was discharged on 18th. Again according to the complainant, the patient was advised to review after 2 weeks. Ext.A21 discharge summary supports the say of the complainant. Discharge summary specifically states ’”review ortho OPD after 2 weeks for check X-ray”. Ext.A21 is seen signed by 1st opposite party Doctor. But according to 1st opposite party patient was discharged on 17th and on 18th the patient reported with pain and swelling of the fingers and on examination it was found that the fingers were swollen and suspecting possibility of compartment syndrome POP cast was wide opened and the gap was covered with single POP bandage. The above said contention of 1st opposite party that the patient was discharged on 17th is not supported by any concrete evidence. The cut and removal of POP and reapplication of the same on 18th by 1st opposite party is admitted by the complainant also. 1st opposite party himself admits in the version that on suspicion of compartment syndrome on 18th , the POP cast was wide opened. In Ext.B1 page 4, compartment syndrome is seen to be recorded. So the question arises whether the procedures and treatment adopted by the opposite party No.1 after suspicion of compartment syndrome is an accepted procedures followed by other Doctors. Complainant has examined by way of commission two Doctors working in Ganga Hospital, Coimbatore wherein the patient has undergone further treatment. Ext.B1 evidences that 1st opposite party has adviced active exercise of shoulders and fingers at the time of discharge. PW2, who is the orthopaedic surgeon attached to Ganga Hospital and who has treated the complainant has deposed the condition of the patient when he saw her on 22/04/2005 as follows: There was swelling on the hand and no movements or sensation was possible on the hand. Because of the lack of blood supply, the skin, muscles and tendons were already dead and had to be removed. PW2 has further deposed that starting of pain and swelling after application of plaster cast is one of the symptom of compartment syndrome. A specific question was put to PW2 that whether usually exercise of finger is adviced when there is pain and swelling after the application of POP for which PW2 answered that usually they make sure that there is no eschemia before advice of finger movements. According to PW2, the patient suffered from Volkman’s eschemia contracture (VEC) and the main causes for the same is either injury to the blood vessel at the time of accident or due to tight plaster. PW2 has calculated the disability of the patients left upper limb as 65-70%. opposite parties has cross examined PW2, but it is seen that nothing has been brought out so as to support the case of the opposite parties. It is true that 2nd opposite party while cross examination has deposed that its a known complication but for the question whether the plaster should be removed as soon as the patient experiencedpain, PW2 answered that it should be immediately cut and removed. On going through the case of the complainant it is seen that complainant has pain and swelling on 18th and opposite party has only partially cut open the POP plaster and the gap was again covered with plaster. According to accepted procedure and according to the opinion of the expert Doctor PW2, it has to be completely opened immediately. So applying Bolam’s Test it can be considered as negligence on the part of opposite party 1. According to PW2, the said situation can be either due to injury to the blood vessels following an accident or due to tight plastering. Opposite parties does not have a case that the patient suffered injury to the blood vessels due to accident. Hence the cause of compartment syndrome can only be due to tight plastering. Had 1st opposite party cut and removed the POP sufficiently earlier, the condition could not have been worsened. PW2 has specifically stated in the re-examination that if the pain was due to compartment syndrome then the delay will cause damage. Evidence shows that the Doctor have suspicion of compartment syndrome on 18th itself. The sufferings of the child is only due to the negligence of 1st opposite party. Again 1st opposite party has contented that contrary to medical advice, complainant reported only on 21st with swelling of fingers and fever. It is also stated that she did not report on 19th or 20th. Submitted that the patient’s relatives were unwilling for admission even though adviced. Opposite parties has not adduced any evidence to show that admission was adviced. Opposite party has admitted that he was not present on that day. POP was also not completely removed on that day. It is only the next day when the complainant reported with fever and discolouration of fingers, POP was completely opened. The said act of the hospital clearly shows how negligently they have dealt with the case of a minor child. It is submitted by opposite parties that the girl was taken to a nearby orthopaedic centre R.V.Clinic for consultation. Evidence shows that the child was referred to R.V.Clinic for amputation. Facts, pleadings, evidence on record and testimony of the experts clearly prove deficiency in service on the part of opposite parties. The sufferings of a school going child due to the act of opposite parties is beyond words and definitely complainant has to be adequately compensated. Issue No.2: Complainant has claimed a total amount of Rs.19,89,000/- as compensation. Complainant produced medical bills for an amount of Rs.5,14,595/- and taxi receipts for journey from Palakkad to Coimbatore hospital to the tune of Rs.73,910/-. Complainant is a minor child aged 7 years. Doctor has assessed disability of the upper limb of the child as 65-70%. Definitely it will affect the future life and marriage prospects of the child. Further the child has lost school for about 2 years. Opposite parties are liable to pay the total bill amount of Rs.5,88,505/- to the complainant. The child has undergone a number of operations on account of the negligence on the part of opposite parties. We quantify compensation for mental agony and suffering of the complainant as Rs.5,00,000/-. Opposite party 2 being the hospital is vicariously liable for the act of its employees. In the result, complaint allowed. Both opposite parties are jointly and severally liable to compensate the complainant. Opposite parties shall pay complainant an amount of Rs.10,88,505/- (Rupees Ten lakhs eighty eight thousand five hundred and five only) being the bill amount together with compensation and Rs.5,000/- (Rupees Five thousand only) as cost of the proceedings. Orders to be complied within one month from the date of receipt of order failing which the whole amount shall carry interest @ 9% p.a from the date of order till realisation. Pronounced in the open court on this the 22nd day of October, 2010 Sd/- Seena.H, President Sd/- Preetha.G.Nair, Member Sd/- Bhanumathi.A.K, Member Date of filing: 22/09/2005 Appendix Witnesses examined on the side of complainant PW1 – Shri.Sasikumar PW2 – Dr.Sabapathy Witnesses examined on the side of opposite parties Nil Exhibits marked on the side of complainant. Ext. A1 – Discharge summary of Ganga Hospital dated 29/06/05 Ext. A2 – Diagnosis report of Department of Plastic Surgery of Ganga Hospital Ext. A3 series - Follow up Summary of Ganga Hospital Ext. A4 series - Discharge Summary of Ganga Hospital Ext. A5 series – Discharge summary of Ganga Hospital Ext. A6 series – Follow Up Summary of Ganga Hospital Ext. A7 series - Follow Up Summary of Ganga Hospital Ext. A8 series - Discharge Summary of Ganga Medical Centre & Hospitals Pvt Ltd Ext. A9 series - Medical bills and cash bills Ext. A 10 series - Cash receipts and medical bills Ext. A11 series – Medical Prescription of Ganga Hospital Ext. A12 series – Cash bills and medical prescription of Ganga Hospital Ext. A13 series – Cash receipt and Cash bill of Ganga Medical Centre & Hospitals Pvt Ltd Ext. A14 series – Cash bills and medical prescriptions of Ganga Hospital Ext. A15 series - Cash bills and medcial prescriptions of Ganga Hospital Ext.A16 series – Tourist Taxi Receipt – 84 Nos. Ext. A17 – Discharge Summary of Ganga medical Centre & Hospitals Pvt Ltd Ext.A18 series - Cash bills Ext. A19 – cash bill Ext.A20 – Cash bills Ext. A21 - Discharge Summary Ext. A22 – Copy of letter from R V Clinic dated 23/02/2007 Ext.22A – Copy of discharge dated 22.04.2005 of R V Clinic Ext.A 23 series - Copy of Lawyer notice dated 25th July 2005 and acknowledgement cards Ext.A24 – Reply notice dated 12/09/2005 Ext.A25 – Followup Summary of Ganga Hospital Ext.A26 – Discharge Summary of Ganga Hospital Ext A27 – Medical prescriptions of Ganga Hospital Ext A28 series – Medical bills Ext A29 – Taxi bills Exhibits marked on the side of opposite parties Ext.B1 – Photocopy of the case sheet of the complainant from Thankam Hospital, Palakkad Ext. B2 – Diagnosis report of Department of Plastic Surgery of Ganga Hospital Ext. B3 series - Follow up Summary of Ganga Hospital Cost (Allowed) Rs.5,000/- (Rupees Five thousand only) allowed as cost of the proceedings
| | [HONORABLE Smt.Bhanumathi.A.K] Member[HONORABLE Smt.Seena.H] PRESIDENT[HONORABLE Smt.Preetha.G.Nair] Member | | 
