SMT. RAVI SUSHA  : PRESIDENT

    This complaint filed U/S 35 of the  Consumer Protection Act 2019, relates to unexpected death of Mrs.Resmi.S. Adhikaram  on 23/6/2019 while under treatment of Dr.C.P. Visaradan, (1^st OP) Consultant General Surgeon,(former surgeon  under service in Army Medical Corps)at Dhanalakshmi Hospital, Kannur(2^nd OP) .  The complainant  alleged gross medical negligence, professional misconduct and deficiency of service resulting to the death of late Mrs.Resmi.S.  1^st complainant  being the husband of late Mrs.Resmi and 2^nd complainant  being the newborn baby of the deceased at the time of death, filed this complaint as legal heirs and successors claiming  compensation for a sum of Rs.1,00,00,000/-(Rupees one crore) from the OPs. 1^st OP is a senior consultant General Surgeon having qualification of  MS with 32 years experience and 2^nd OP  Dhana Lakshmi Hospital is a  private hospital.  Deceased Mrs.Resmi.S.Adhikaram was working as a staff nurse under Govt. of Kerala.  1^st complainant is also a qualified nurse.

     It is the case of the complainants that  on 22/6/2019 at about 7.P.M  the wife of the complainant Resmi complained  about  discomfort in stomach.  She consulted RMO of 2^nd OP made a provisional diagnosis of  gastritis and prescribed medicine.  At about 8.30 P.M  the patient aggravated and  she started  complaining unbearable pain in the abdomen, the RMO again prescribed medicines for gastritis.  Since the pain  in the stomach area gradually increased, the 1^st complainant  being a qualified nurse requested the duty nurse and RMO concerned for a n emergent surgical consultation as the patient was experiencing unbearable pain and her physical condition was deteriorated. At about 11.P.M 1^st OP came to the hospital  and examined the patient and prescribed medicines and admitted.  Subsequently the physical condition of the patient was further deteriorated and the 1^st complainant  was constrained to  make request to  call 1^st OP.  Whereas 1^st OP was not willing to attend the patient and he prescribed some tablets and pain killer injection through phone. 1^st complainant states that about  1.A.M on 23/6/2019, the  physical condition of the patient became more and more severe and as per the compelling request of 1^st complainant she was shifted to ICU by around 1.30 A.M.  The 1^st complainant had to assist the duty nurse to shift the patient to ICU in a trolley which was available in the 1^st floor where she was admitted.  No arrangements were made in the ICU to receive an emergent patient though the duty nurse had informed the ICU staff  half an hour earlier regarding the dangerous physical condition of the  patient.  No qualified nursing staff nor the 1^st OP or any other qualified medical professionals were available in the ICU.  When the patient was shifted to  ICU.  After admitting  the patient in the ICU the serious condition of the patient was not disclosed to the 1^st complainant either by the nursing staff or by the RMO concerned.  By around 2.30 A.M the 1^st OP came to the hospital and informed that the patient is having some breathing problem and she is put on ventilator and she would be alright after some time.  After that the death of the patient was informed to the 1^st complainant  at about 4.00 A.M. As per the post mortem report cause of death of Resmi  was  herniation of the stomach, intestines and spleen into the chest cavity through a congenital  diaphragmatic defect( diaphragmatic hernia). It is submitted that the   death of  Resmi  was  caused due to  gross negligence, carelessness and deficiency of service of 1^st OP. Hence the complaint.

   After receiving notices, OPs filed their version jointly denied the allegations of the complainants.  It is submitted that, at 6.50 P.M on 22/6/2019 the patient(deceased Resmi S Adhikaram) reported to the  casualty with complaints of abdominal pain and vomiting, on clinical assessment her vitals recorded as temperature normal, pulse 70/mt, BP 120/90 MM Hg, SPO2 96% and respiratory rate 22/mt.  No abnormality was detected in cardio-vascular system and respiratory system other than abdominal  symptoms.  According to 1^st OP her abdomen was  soft, epigastritic tenderness present and bowel sounds were present.  There was no abdominal detention and the patient did not complaint any respiratory symptoms or  anything suggestive of suspecting  intestinal abstraction.  It is also submitted that 1^st OP had prescribed medicines to the deceased from time to time. On the basis of clinical history and examination findings 1^st OP made a diagnosis of acute gastritis and the patient was admitted for further management.  Reportedly the patient had history of similar abdominal complaints  one week back and cured with medicines and since she had no significant changes in vitals and no respiratory complaints it was decided to manage conservatively with supportive medication on a provisional diagnosis of acute gastritis.  According to 1^st OP the sudden onset of nausea, vomiting and abdominal pain developed on 22/6/2019 was not reportedly preceded by any history of trauma to suspect possibility for acquired internal abdominal injury to advice investigations like X-ray or scanning. 1^st OP contended that the sudden deterioration and death of the patient  caused  as due to diaphragmatic hernia as detected in postmortem cannot attribute to be caused  due to any act or omission on  his part or  any staff of the 2^nd OP hospital. 1^st OP submitted that the patient’s SPO2 level remained normal until 3 A.M, she  exhibited no symptoms that would suggest diaphragmatic hernia.  It is explained that from  the time to time of the  first consultation by the RMO until 3.A.M, the patient did not exhibit symptoms of diaphragmatic hernia.  During this period, she was treated  for gastritis, receiving medication for symptomatic relief, which alleviated her pain.  It is possible that the congenital hernia may have ruptured after 3 A.M, leading to the subsequent problems.  This conclusion is supported by an examination of the patient’s symptoms from 11 P.M to 3 P.M, as recorded in the case sheet.  1^st OP prescribed cyclopam injection at 1.30 A.M which is an  analgesics for symptomatic relief.  The condition  of the patient  was not serious at 1.30 a.m  and patient’s condition was stable with  injection  cyclopam.  Congenital diaphragmatic herniation is a extremely rare condition for a person to live 33 years and succumb to sudden death to  its complication manifested with early symptoms  as seen in acute gastritis.  The 1^st OP is  a responsible medical practitioner having MS qualification in General Surgery and unblemished track records of 32 years of consultation.  There was no  negligence or deficiency in service on the part of OPs.  Hence prayed for the dismissal of the complaint.

     At the evidence stage five PWs including the 1^st complainant  was examined on the side of  complainant and they were subjected to cross-examination by the OPs.  Exts.A1 to A9 were marked.  From the side of OPs, 1^st OP filed his chief affidavit and was examined as DW1.  Exts.B1&B2 and B2(a) were marked.  After that the learned counsels also vehemently argued their contentions. The learned counsel of complainant submitted Text book of  short Practice  of Surgery for reference.

   The argument of learned counsel of  complainant is that on  account of the negligence and deficiency of service on the part of 1^st OP, the death of Mrs. Resmi was happened.  Further submitted that 1^st OP could have very well diagnosed the illness of the deceased congenital Diaphragmatic Hernia, by taking X-ray about 11.P.M on 22/6/2019, and if he exhibited  the minimum standard of care and professional skill expected from an experienced General surgeon, the life of Resmi could have been saved.

  From the medical documents availed on records, evidence adduced by parties, evidence of PWs 2 to 5 doctors and also the arguments submitted by the learned counsels  appearing for parties, the points to be decided by this commission  are (1)whether there was medical negligence  amounting to deficiency of service on the part of OPs? (2) If so what relief can be given to the complainants.

 Point Nos.1 &2:

  The undisputed facts in this case are that the deceased Mrs.Resmi Adhikaram was admitted in 2^nd OP hospital with pregnancy complications on 10/6/2019.She underwent a cesarean on 10/6/2019 and was  discharged  on 15/6/2019.  Since 2^nd complainant was  in ventilator after cesarean, the deceased Resmi was staying in the hospital.  Further on 22/6/2019 at about 7.P.M the said Resmi complaint  about discomfort in stomach(abdominal pain) and was consulted by R.M.O at casualty of OP hospital.  RMO made a provisional diagnosis of gastritis and prescribed Inj.pantop 4mg, Inj-Emieset 4 mg Inj.Dynapar(medicines for gastritis and pain killer) and sent to room.  Further undisputed fact is at 11.p.m complaint of persistence of abdominal pain, 1^st OP came to hospital as per the phone call of RMO and examined the patient.  Provisional diagnosis of 1^st OP was gastritis, and prescribed medicines for gastritis.  Further at 1.30 A.M as the patient  complained pain abdomen  Inj.Cyclopam was given as per the instruction of 1^st OP over phone .  Further at 3.A.M patient again complained  and at 3.30 A.M 1^st OP came to hospital.  Further at 4.a.M death of the patient was declared. Further post mortem examination was conducted on the  body  of the deceased Resmi, at Pariyaram Medical college Hospital,  and opinion as to the  cause of death was “died of herniation of the stomach, intestines and spleen into the chest cavity through a congenital  diaphragmatic defect( diaphragmatic hernia).

   At this stage it is to be observed that 1^st OP had not done any investigation proceedings even not taken X-ray for arriving a final diagnosis.  From the records it is evident that provisional diagnosis of the patient was gastritis.  1^st OP had not done any investigation proceedings even not taken X-ray for arriving a final diagnosis.  From the  records it is evident that provisional diagnosis of the patient was gastritis.  1^st OP explained as, at 6.50 P.M on 22/6/2019 the patient reported to the  casualty with complaints of abdominal pain and vomiting, on clinical assessment her vitals recorded as temperature normal, pulse 70/mt, BP 120/90 MM Hg, SPO2 96% and respiratory rate 22/mt.  No abnormality was detected in cardio-vascular system and respiratory system other than abdominal  symptoms.  According to 1^st OP her abdomen was  soft, epigastritic tenderness present and bowel sounds were present.  There was no abdominal detention and the patient did not complaint any respiratory symptoms or  anything suggestive of suspecting  intestinal abstraction.  It is also submitted that 1^st OP had prescribed medicines to the deceased from time to time. On the basis of clinical history and examination findings 1^st OP made a diagnosis of acute gastritis and the patient was admitted for further management.  Reportedly the patient had history of similar abdominal complaints  one week back and cured with medicines and since she had   no significant changes in vitals and no respiratory

complaints it was decided to manage conservatively with supportive medication on a provisional diagnosis of acute gastritis.  According to 1^st OP the sudden onset of nausea, vomiting and abdominal pain developed on 22/6/2019 was not reportedly preceded by any history of trauma to suspect possibility for acquired internal abdominal injury to advice investigations like X-ray or scanning. 1^st OP contended that the sudden deterioration and death of the patient  caused  as due to diaphragmatic hernia as detected in postmortem cannot attribute to be caused  due to any act or omission on  his part or  any staff of the 2^nd OP hospital. 1^st OP submitted that the patient’s SPO2 level remained normal till 3 A.M, she  exhibited no symptoms that would suggest diaphragmatic hernia.  It is explained that from  time to time of the  first consultation by the RMO until 3.A.M, the patient did not exhibit symptoms of diaphragmatic hernia.  During this period, she was treated  for gastritis, receiving medication for symptomatic relief, which alleviated her pain.  It is possible that the congenital hernia may have ruptured after 3 A.M, leading to the subsequent problems.  This conclusion is supported by an examination of the patient’s symptoms from 11 P.M to 3 P.M, as recorded in the case sheet.

      Learned counsel for the complainant stated that 1^st OP did not  properly apply his mind and ability to the condition of the deceased on 22/6/2019.  From the medical records it is clear that 1^st OP was fully qualified to deal with the complaint of the deceased.  From the prescriptions it is clear that at11.00 P.M on 22/6/2019, the patient was  consulted and treated by RMO Dr.Hilal. 1^st OP came and examined the deceased at 11.30 P.M on 22/6/2019.  The RMO examined the patient and initial assessment was  c/o Abdominal pain and multiple episode of vomiting. P/A “diffused tender”.    It is  to be noted that  on the 1^st time  of consultation itself there was diffused tender with C/o Abdominal pain(Diffuse abdominal tenderness can be a symptom of gastritis, Diverticulitis ,IBD, Abdominal abscess, “certain types of hernias”.  Here RMO prescribed and administered Inj. Pantop and emeset.  Medicines for gastritis.

    From the prescription records available before us, it is seen that she was again taken to the casualty at 11.p.m.c/o abdominal pain.  Then gave Inj.Dynapar(effective in relieving pain and inflammation).  RMO referred the patient to surgeon Dr.Visharadan(1^st OP) and informed to 1^st OP over phone.  1^st OP came at 11.30.P.M and admitted the patient in room at 11.56.P.M.  Then also complaint of the patient was Diffused Abdominal pain, Nausea.  The provisional diagnosis of 1^st OP was acute gastritis .  It is alleged by the complainant that at the time of examination by 1^st OP, the deceased told him that her intestines were entangled and that she was unable to breath beyond the abdominal level.  Further 1^st complainant said that she was complaining of intestinal obstruction and requested him to do the necessary investigations.  But the 1^st OP opined that the pain was due to gastritis which was a side effect of caesarean section.

    Next time of assessment was 12.35 A.M. Diagnosis c/o abdominal pain.  At.1.30 A.M by stander(1^st complainant) informed, complaint of chest discomfort, ask to sedative injection. Case was informed to 1^st OP telephonically, advised inj.cyclopam(pain killer) used in the treatment of abdominal pain and irritable bowel syndrome.  At.1.40 P.M inj.cyclopam was given.  As per the case record ,Nurses record, it is evident that at 3.A.M patient has c/o Fatigue gasping and abdominal pain.  B/P 100/70 SPO2 97%.  As per record the patient was shifted to ICU at 3.A.M at 3.10 A.M patient collapsed.  CPR initiated.  Death declared at 4.30.A.M.  It is recorded in Nurses record that at 3.30 A.M case seen by Dr.Visharadhan , advised to continue CPR.

   1^st complainant  alleged medical negligence on the part of 1^st OP,  on the ground that inspite of his request the doctor(1^st OP) failed to do any investigations, even a

simple investigation like X-ray chest would have diagnosed the condition and thus prevented the death.  According to him the patient was shifted to ICU as he wanted to ICU observation.

  In the postmortem examination, the cause of death was  given  as “ herniation of the stomach, intestines and spleen in to the  left chest cavity, a case of diaphragmatic hernia “ Left lung was completely collapsed due to the pressure exerted by the herniated organs.  Right lung was partially collapsed.

   Further complainant alleged that about  1.A.M on 23/6/2019, the  physical condition of the patient became more and more severe and as per the compelling request of 1^st complainant she was shifted to ICU by around 1.30 A.M.  The 1^st complainant had to assist the duty nurse to shift the patient to ICU in a trolley which was available in the 1^st floor where she was admitted.  No arrangements were made in the ICU to receive an emergent patient though the duty nurse had informed the ICU staff  half an hour earlier regarding the dangerous physical condition of the  patient.  No qualified nursing staff nor the 1^st OP or any other qualified medical professionals were available in the ICU when the patient was shifted to  ICU.  After admitting  the patient in the ICU the serious condition of the patient was not disclosed to the 1^st complainant either by the nursing staff or by the RMO concerned.

   During cross examination of PW1 , he deposed that പുലർച്ചെ3 മണിയോടെ രോഗിയെ ICU  വിലേക്ക്മാറ്റി. രോഗിക്ക് വയറുവേദന വർദ്ധിക്കുകയും തളർച്ച ഉണ്ടാവുകയും ചെയ്തതിനാൽ RMO പറഞ്ഞതിനനുസരിച്ചാണ് ICU  വിലേക്ക്മാറ്റിയത്?ശരിയല്ല ഞാൻ പറഞ്ഞിട്ടാണ്  ICU  വിലേക്ക്മാറ്റിയത്.    

  OP has submitted Ext.B2 IP Register-ICU for the period from 1/5/2019 to 26/7/2021.  Ext.B2(a) is the relevant page dtd.23/6/2019.  On verifying Ext.B2(a) it is stated that the patient was admitted in ICU on 23/6/2019 at 3.15.A.M.  In version it is stated that  at 3 A.M the patient was shifted to ICU.  On a keen perusal of Ext.B2(a) we can see that  serial No. of Padmini(1^st person) and Resmi S Adhikaram(deceased in this case) are 24 in number.  On  verifying the entire pages in Ext.B2 all other numbers are in a contiguous order uninterrupted.  Further except Resmi, others persons admission time is mentioned on the second column.  This reveals some suspicion in the admission time of patient in ICU as alleged by 1^st OP.  It is a fact that 1^st OP came there only at 3.30.A.M after collapse of patient and shifted to ventilator.

   The main argument of 1^st OP is that the patient’s oxygen saturation level remained normal until  3 A.M which means she did not have breathing issues.  It is submitted that at around 1.30 A.M, deceased first complaint about breathing difficulty, but then also  her SPO2 level was 97%.  Moreover as per abdominal examination abdomen was found soft .  No mass and bowel sounds present and only positive finds was tenderness of upper abdomen.  Further the patient had  similar complaints severe nausea +diffused  and abdominal pain for one week back treated with Pandop and syrup. Hence 1^st OP did not  suspect diaphragmatic hernia and not advised investigations like X-ray or scanning.  It is also  submitted that as per clinical history and presenting complaints shown by the  patient, the clinical diagnosis of acute gastritis and  conservative  management with  medication was well within the accepted norms of medical practice and treatment protocol.  According to 1^st OP, it is possible that the congenital hernia may have ruptured after 3 .A.M leading to the subsequent problems.

   In this situation, we have to decide whether the decision taken by 1^st OP that it was not necessary to take any investigation  on the  patient as there was no such clinical symptoms on her is correct or not?

   At this junction we have to analysis the depositions given by PWs 1 to 5 and DW1.

    On analysis of evidence of PW1.

    One of the allegation of the 1^st complainant is that the case records(Ext.B1) was manipulated by OPs.  He deposed that ” OP ഹാജരാക്കിയ രേഖകളിൽ ഏതെങ്കിലും രേഖകൾ manipulation നടന്നതായി തോന്നിയോ? തോന്നിയിരുന്നു. Vomiting ഉണ്ടായിരുന്നു എന്ന് കേസ് ഷീറ്റിൽ  പല സ്ഥലത്ത് എഴുതിയതായി കാണുന്നു. Wife ന് nausea മാത്രമേ ഉണ്ടായിരുന്നുള്ളൂ.നഴ്സസ് റെക്കോർഡ്സ് വളരെ കൃത്യമായിട്ടാണ് എഴുതിയത്.  അത്തരത്തിൽ ഒരു നഴ്സസ് റെക്കോർഡ്സ് സീരിയസ്സായ പേഷ്യന്ർറിന്ർറെ കാര്യത്തിൽ എഴുതാൻ സാധിക്കില്ല.  അതുകൊണ്ട് എഴുതി ഉണ്ടാക്കിയതാണ്.”

   On perusal of prescription dtd.22/6/2019 at 7.11 P.M(first consultation) at casualty, the injection prescribed by RMO was Inj. Pandop(to reduce the amount of acid produced in the stomach) and Inj. Eemiset (commonly used to control nausea and vomiting).  In  the prescription of 1^st OP at 11.56 P.M, it is seen recorded by 1^st OP, that   reason for admission” Nausea, diffused  abdominal pain”.  In Nurses record  it is noted that on 22/6/2019, at 11.10.P.M” New patient came from casualty with the complaint of abdomen pain and Nausea”. It can be seen that vomiting is not recorded by duty nurse.  If there was complaint of vomiting, the said  complaint of vomiting and its frequency  would have been recorded by nurse.  For establishing the contention of OPs , they could have examine the concerned RMO.  Hence from the above facts recorded from the medical sheets, we can  reveal that the patient had only “ Nausea and  abdomen pain” at the initial stage of  consultation at casualty.  So recording of vomiting in the case sheet is seems to be a manipulation.

   Here 1^st OP himself admitted that there was recurrent abdominal pain even after given pain killer injection for subsiding pain and for gastritis.

   During cross examining  PW1, the learned counsel of OP put questions that ” 11 മണിക്ക്  1^st OP കൊടുത്ത ഇഞ്ചക്ഷൻ കൊണ്ട് വേദന ചെറുതായി കുറഞ്ഞു.  വീണ്ടും വേദന വരുന്നത് 1½ മണിക്കാണ് എന്ന് പറഞ്ഞാൽ? 1½ മണിക്കും 2മണിക്കും ഇടയിലാണ്.  അപ്പോൾ വീണ്ടും ഇഞ്ചക്ഷൻ നൽകി അപ്പോൾ വേദന കുറഞ്ഞ് 3 മണിക്ക് വീണ്ടും വേദന വന്നു എന്ന് പറഞ്ഞാൽ? അരമണിക്കൂർ കഴിഞ്ഞു വീണ്ടും വേദന വന്നു ”

    On verifying the prescription and nurses record we can  understand that pain killers and IVF were given repeatedly.  So subsiding of pain for some time after administering  such  injections is usual.  It is seen that there was  reporting of complaint of abdominal pain recurrently.

   So from the  deposition of PW1 as a whole, we cannot assume that the allegations raised by the complainant are false.

   Next PW2 is Dr.S.Gopalakrishna Pillai, MD in Forensic Medicine, LLB having experience of 26 years as surgeon, who conducted post-mortem on the body of deceased Resmi and submitted report(Ext.A2).  In Ext.A2 the finding of Forensic surgeon  about cause of death of deceased Resmi.S. Adhikaram in Crime No. 701/19 of Kannur Town Police station as “Died  of herniation of the stomach ,intestines and spleen into the chest cavity through a congenital diaphragmatic defect(diaphragmatic hernia).   It is observed that “ Left dome of the  diaphragm was seen bulging in to the abdominal cavity, on dissection, a congenital defect(7x5.5cm) was seen in the left dome of diaphragm through which, the stomach with its contents, spleen, transverse colon and coils of small intestine were found herniated in to the left chest cavity. Left lung was completely collapsed due to the pressure exerted by the  herniated organs.  Right lung was partially collapsed.  Liver showed fatty changes and was congested.”

  PW2 has been examined in chief  and cross elaborately.  On analysis of his evidence, we can reveal  that the doctor has given deposition in tune  of his observation as stated in Ext.A2.  Further in page 3 “  ഇതുമായി ബന്ധപ്പെട്ട് പോലീസ് രജിസ്റ്റർ ചെയ്ത കേസിൽ താങ്കൾ പോലീസിന് മൊഴികൊടുത്തിരുന്നു? ശരിയാണ്. പോലീസിൽ കൊടുത്ത മൊഴി പ്രകാരം ആമാശയം ഭക്ഷണ സാധനങ്ങൾകൊണ്ട് നിറഞ്ഞതിനാൽ ഡൈഫ്രത്തിലെദ്വാരത്തിൽ കൂടി തിരിച്ചിറങ്ങിവരാൻ കഴിയാതെ വന്നതാകാം. Diaphragmatic hernia ഒരു സർജൻ diagnose ചെയ്താൽ എന്താണ് ഒരു രോഗിയെ മരണത്തിൽ നിന്ന് രക്ഷിക്കാൻ സാധാരണ ചെയ്യുന്നത്? മൂക്കിൽകൂടി ആമാശയത്തിലേക്ക് ഒരു ട്യൂബ് ഇട്ടിട്ട്,ആമാശയത്തിലുള്ള ഫുഡും ജലാംശവുമെല്ലാം suck ചെയ്ത് പുറത്തേക്ക് എടുക്കുക, അപ്പോൾ ആമാശയം ചുരുങ്ങും അപ്പോൾ ആമാശയം താഴെക്കിറങ്ങിവരും അതിനുശേഷം ഓപ്പറേഷൻ ചെയ്യണം, പിന്നീട് ഡൈഫ്രത്തിലുള്ള ദ്വാരം തയ്ക്കണം”.

   1st OP has taken a contention that though diaphragmatic  hernia was diagnosed, the life of this  disease could not be saved.

  Further PW2 deposed that ഠഎന്തൊക്കെ diagnostic method ലാണ് Diaphragmatic hernia കണ്ടുപിടിക്കുന്നത്?  clinical examination നെഞ്ച് പരിശോധിക്കുമ്പോൾ അവിടെ ശ്വാസകോശത്തിൽ air കയറുന്നില്ലയെന്ന്മനസ്സിലാകും bowel sounds നെഞ്ചത്ത് കേൾക്കും, അതിന് കാരണം ചെറുകുടൽ chest ൽ കയറിയതുകൊണ്ട്, അടുത്തതായി chest X-ray ആണ്. chest X-ray എടുക്കുമ്പോൾ gas നിറഞ്ഞ ചെറുകുടലിന്ർറെ ഭാഗങ്ങൾ ഇടതുവശത്തെ നെഞ്ചിനകത്ത് കാണപ്പെടും  intestinal shift x-ray  യിൽ കാണാം, ultra sound san, CT scan, MRI san etc.  Diaphragmatic hernia എന്ന രോഗാവസ്ഥ കണ്ടുപിടിക്കാൻ സാധിച്ചെങ്കിൽ ഈ സ്ത്രീയുടെ ജീവൻ രക്ഷിക്കാൻ സാധിക്കുമോ? സാധിക്കും. ഇതിനുള്ള ചികിത്സ സർജന്ർറെ ഫീൽഡ് ആണ് എന്നു പറഞ്ഞാൽ? ഒരു Gastro surgeon, Thoracic surgeon, Experienced General surgeon”.

   1^st OP submitted that as per abdominal examination findings abdomen was soft, no mass and  bowel sounds present and  only positive finding was tenderness of upper abdomen.

    On perusal of  prescriptions of 1^st OP these systems were recorded by 1^st OP only after initial assessment and provisional diagnosis was acute gastritis.  Except initial assessment at his first examination, no such recordings can be seen in Doctors record in further or Nurses record.  1^st OP, admits that at that time there was tenderness of upper abdomen.  In  upper abdomen, many important organs, including  the stomach, liver, pancreas, spleen, kidneys, gall bladder and parts of the small and large intestines.  As per abdominal examinations findings at 11.56 P.M, there was tenderness at the upper abdomen of the patient.  In Ext.A2  post-mortem certificate cause of death was due to herniation of the stomach ,intestines and spleen ie, parts of the upper abdomen into the chest cavity through a congenital diaphragmatic defect”.

  So the  1^st OP‘s contention that  there was no positive symptoms for diaphragmatic hernia  appeared on the patient till 3.p.m on 23/6/2019 cannot be accepted. By around 1.30.A.M, the patient had complaint of chest discomfort

   During  cross examination PW2 the learned counsel of OP put a question  to PW2 in  page 6 ” ഒരു രോഗി ഒരാഴ്ച മുൻപ്  വയറുവേദനക്ക് ഡോക്ടറെ കണ്ട് മരുന്ന് കഴിച്ച് രോഗം ഭേദമായി പിന്നീട് ഒരാഴ്ചക്ക് ശേഷം വീണ്ടും വയറുവേദനയുമായി വന്നാൽ വീണ്ടും മരുന്ന് കൊടുത്ത് രോഗം മാറ്റാനാണ് ആ ഡോക്ടർ ശ്രദ്ധിക്കുകയെന്നു പറഞ്ഞാൽ? അങ്ങനെയും  ചിന്തിക്കാം. പിന്നീട് വേദന വരുമ്പോൾ വേറെ എന്തെങ്കിലും കാരണം കൊണ്ടാണോ എന്നും ചിന്തിക്കാം.  രണ്ടാമത് വരുന്നത് severe  ആയ pain ആണെങ്കിൽ മറിച്ച് ചിന്തിക്കണം.”

   From this we can realize that at the  first examination of the deceased  by 1^st OP at 11.55.P.M the provisional diagnosis was Acute gastritis and gave medicines for  gastritis.  Giving of the said treatment we cannot blame 1^st OP as one week back such a situation was occurred and it was managed in medicines.  In fact, after giving the medicines by RMO from  7 P M onwards for  the complaint of gastritis, along with

pain killers, as the  symptoms of pain developed again and  in a severe manner, and shows symptoms of upper abdominal  tenderness  at 11.55 P.M, 1^st OP should have  thought about other complications in the patient and advised to take investigations.

     PW2 further  emphasis the said  point in another  question of  OP’s counsel   in page 7 “ ഒരു IP ആയ രോഗിക്ക് മരുന്ന്കൊണ്ട് വേദനകുറയുന്നതായി കണ്ടാൽ അസുഖം പൂർണ്ണമായും മരുന്നുകൊണ്ട് മാറും എന്ന് ഡോക്ടർ വിചാരിച്ചാൽ തെറ്റ് പറയാൻ പറ്റില്ല? ഇല്ല. അത്തരം സാഹചര്യത്തിൽ വേറെ clinical laboratory examination വേണ്ടെന്ന് ഡോക്ടർ വിചാരിച്ചാൽ തെറ്റില്ലേല്ലും ? തെറ്റില്ല ശരിയാണ് . വയറുവേദനയും , ഓക്കാനവും ,ഛർദ്ദിയും മാത്രമുള്ള ഒരു രോഗിക്ക് CDH ഉള്ളതായി സംശയിക്കാൻ കഴിയില്ല? ഇല്ല ശരിയാണ്.  ഈ രോഗലക്ഷണങ്ങളുടെ കൂടെ ശ്വാസതടസ്സവും നെഞ്ചുവേദനയും ഉണ്ടെങ്കിൽ വയറിന്ർറെ മാത്രം കുഴപ്പമല്ല ,വേറെ എന്തോ കുഴപ്പം ഉണ്ട് എന്ന് investigate ചെയ്ത് കണ്ടുപിടിക്കണം.”

    From the case records, it is clear that in each time of complaining, 1^st OP had given medicines for  acute gastritis along with strong pain killers.  So subsiding of pain for sometimes after applying pain killer injections are  normal.  Further  in page 8 of deposition   also PW2 stated that “ഒരു വയറുവേദനയും, ഛർദ്ദിയും, ഓക്കാനവും ഉള്ള രോഗിയെ അപ്പോൾതന്നെ X-ray എടുത്തില്ല CT scan എടുത്തില്ല എന്നു പറഞ്ഞ് ഡോക്ടറെ കുറ്റപ്പെടുത്താൻ സാധിക്കുമോ? സാധിക്കില്ല. മരുന്ന് കൊടുത്ത് രോഗം വർദ്ധിക്കുകയോ നേരത്തേയുള്ള ലക്ഷണത്തിൽ നിന്ന് മാറി വല്ല ലക്ഷണവും കാണിച്ചാൽ  തീർച്ചയായും investigation നടത്തണം.Ext.B1 page-5(shown to witness) SPO2 98% രേഖപ്പെടുത്തിയിട്ടുണ്ട്. അതിന്ർറെ അർത്ഥം ആ സമയത്ത് Oxygen saturation normal  ആയിരുന്നു എന്നാണ്.

   In re-examination  ഒരു qualified ആയ നേഴ്സ് ആയ രോഗി എന്താണ് നിങ്ങളുടെ complaint എന്ന് ഡോക്ടർ ചോദിച്ചപ്പോൾ എന്ർറെ കുടല് പിരിഞ്ഞിരിക്കുന്നു എന്ന് പരാതിപ്പെട്ടാൽ investigation നടത്തണോ? നടത്തണം എന്നാണ് എന്ർറെ അഭിപ്രായം.”

   The defence point raised by 1^st OP is that until 3.A.M, SPO2 showed in normal rate.  According to OP it means, there was no respiratory problem.  As alleged by complainant, SPO2 and other vital parameters are recording by the staff nurse. As far as commission in concerned, we cannot take a decision  by considering from the SPO2 rate alone, because the case records are in the custody of OPs.  We can see that there is some confusions in the entries in Ext.B2(a).

   Further PW3 and PW4 are medical practitioners working in Health department.  PW3 as Additional Director(Vigilance).  On analysing his evidence as a whole, he is supporting the allegations of the complainant.

   Evidence of PW4, she was the convenor in State level Apex body, constituted in connection with Crime No.701/2019 Kannur Town Police station with regard to the death of Resmi S. Adhikram(deceased in lieu) to find out whether there was negligence from the part of treating doctor for giving treatment and timely diagnosis .  A district level committee was already constituted in connection with the above said crime, and after perusing  relevant documents including post-mortem report, the members of the panel could not reach at a unanimous decision, therefore it was decided to forward the case to the state panel of experts.  The District level report is marked as Ext.A10(a) and state level report as Ext.A8.  In Ext.A8 the Apex body is  of the opinion that there is negligence for getting treatment and timely diagnosis from the part of treating doctors of Dhanalakshmi Hospital,Kannur.  The committee arrived such a decision after perusing(1) case sheet, (2) Report of District level Expert Panel Report(3) Post mortem Report (4) Expert opinion  of Gynaecologist, Surgeon and Cardio Vascular thoracic surgeon.  In Ext.A8, it was opined that the treating doctor failed to do any investigations, even a simple investigation like X-ray chest would have diagnosed  the condition and thus prevented her death.

   On perusal of the evidence of PW4, the Doctor deposed that in page 3 ” surgeon വന്ന് patient നെ പരിശോധിച്ച്, admit  ചെയ്തു. patient െൻറ അപ്പോഴുള്ള complaint ശ്വാസം എടുക്കാനുള്ള ബുദ്ധിമുട്ട് abdomen  ന് മുകളിലേക്ക് പറ്റുന്നില്ല എന്നതായിരുന്നു. Basic lab test കളായ ECG,X-ray, USG എന്നിവ എടുത്തില്ല.  X-ray എങ്കിലും എടുക്കേണ്ടതായിരുന്നു. Investigation നടത്താതെ അദ്ദേഹം gastritis കൊണ്ടാണ്    ഇങ്ങനെ സംഭവിക്കുന്നതെന്ന്  പറഞ്ഞു”.

   In case record, it is mentioned that  complaint of tenderness in upper abdomen at 11.55 p.m.  Abdominal tenderness is generally a sign of inflammation or other sudden process in 1 or more organs surrounding the tender area”.

   Further deposed that “ basic investigation X ray എടുത്തിരുന്നെങ്കിൽ  patient െൻറ life save ചെയ്യാമായിരുന്നു surgery നടത്തിയിട്ടെങ്കിലും,അല്ലെങ്കിൽ higher centre ലേക്ക് പെട്ടെന്ന് refer ചെയ്യാമായിരുന്നു. Post mortem report ൽ   left side lungs മുഴുവൻ collapse ആയിരുന്നു.  Right side partially collapse   ആയിരുന്നു.  ആയത് X ray യിൽ കണ്ടുപിടിക്കാമായിരുന്നു. 7 മണിമുതൽ body യിൽ symptoms കാണിച്ചിരുന്നു. സമയം waste ചെയ്യാതെ X ray or USG എടുത്തിരുന്നെങ്കിൽ life save ചെയ്യാമായിരുന്നു”.

   On the side of complainant Dr.Sreejayan M.P Professor of Surgeon, M.D in surgery, National Board, PHD in surgery, FRCS from Royal college of surgeons of Eedinburg and also FRCS from Royal college of surgeons  England, working as surgery professor, Superintendent   in Govt Medical college Hospital, Kozhikode, was examined as an Expert medical witness.  Examined as PW5.  He has 32 years  experience in surgery.  He has  given evidence before  the commission after examining post mortem  report of deceased Resmi S Adhikaram, case sheet of OP2 hospital in connection with her treatment Reports of District level committee and State level committee.

   On analysing the evidence of PW5, we can reveal that the Expert Doctor has deposed in page 2 of his deposition “Diaphragmatic hernia എന്ന condition diagnose ചെയ്താൽ രോഗിയുടെ ജീവൻ രക്ഷിക്കാൻ ഒരു surgeon standard protocol പ്രകാരം ചെയ്യുക ? operation കൊണ്ടു മാത്രമേ അത് അകറ്റാൻ പറ്റുകയുള്ളൂ.   Diaphragm  ത്തിലുള്ള hole ൽ കൂടി intensive  അനുബന്ധ organs മുകളിലേക്ക് കയറിയാൽ surgery യ്ക്കു   മുൻപേ ചെയ്യേണ്ട  procedure  എന്താണ്? Diaphragmatic hernia ഉണ്ടോ എന്നുള്ള സംശയം doctor ക്കു വേണം. അങ്ങനെ ഒരു സംശയം ഉണ്ടായാൽ സ്ഥിരീകരിക്കാനുള്ള പരിശോധനകൾ വേണം. ഒരു simple test എന്ന രീതിയിൽ വയറിന്ർറേയും  നെഞ്ചിന്ർറേയും X-ray ആവശ്യമാണ്. During cross examination PW5 stated that “ വയറുവേദനയുമായി വരുന്ന സ്ത്രീകളുടെ വയറ് doctorമാർ കൈകൊണ്ട് വയറ് അമർത്തിനോക്കും? നോക്കും. വയറുതൊട്ടുനോക്കുന്ന സമയത്ത് soft ആണെന്ന് കണ്ടാൽ ഗുരുതരമായി പ്രശ്നങ്ങൾ ഇല്ലെന്ന് doctor ക്കു അനുമാനിക്കാൻ സാധിക്കും? അതെ. വയറ് പരിശോധിക്കുന്ന സമയത്ത് bowel sound  ഉണ്ടെങ്കിൽ അപ്പോൾ കുഴപ്പമില്ലെന്ന് അനുമാനിക്കാം? അതെ. രോഗിക്ക് കുറച്ച് ദിവസം മുൻപ് മരുന്ന് കൊടുത്ത് വേദന മാറിയിരുന്നെങ്കിൽ പിന്നീട് അതേപോലെ വയറു വേദന വന്നാൽ നേരത്തേ കൊടുത്ത മരുന്ന് തന്നെയാണ് doctorമാർ  നൽകുക എന്നു പറഞ്ഞാൽ ശരിയാണോ? അതേ ലക്ഷണമാണെങ്കിൽ repeat ചെയ്യാം. ഓരോ പ്രാവശ്യവും രോഗി വരുമ്പോൾ രോഗത്തിന്ർറെ ലക്ഷണവും പരിശോധനയും നടത്തി തീരുമാനമെടുക്കേണ്ടതാണ്. പരിശോധനയ്ക്കുശേഷം തീരുമാനം പഴയതു തന്നെയാണെങ്കിൽ ആ മരുന്ന്  repeat ചെയ്യാം. Further deposed that ഈ case sheet(Ext.B1)നോക്കിയാൽ രോഗിക്ക് breathless ഉള്ളതായി പറഞ്ഞിട്ടുണ്ടോ? ഇല്ല . case sheetൽ രേഖപ്പെടുത്തിയ symptoms പ്രകാരം patientന്  gastritis ആണെന്ന് പറഞ്ഞാൽ? 11.30 PM വരെയുള്ള diagnosis  അതായിരിക്കാം. UP to 3 A.M രോഗിയിൽ symptoms ൽ എന്തെങ്കിലും variation ഉണ്ടോ? 1.30 A.M ന് chest discomfort ഉണ്ട് എന്ന് പറഞ്ഞിട്ടുണ്ട് .  Further stated that 3 മണിക്ക് ശേഷമായിരിക്കാം diaphragmatic hernia അവർക്ക് complicated ആകുന്നത് എന്നു പറഞ്ഞാൽ? പൂർണ്ണമായും ശരിയല്ല.  കാരണം patient ന് 1.30 A.M  മുതൽ breathing difficulty ഉണ്ടായിരുന്നു. അത് ഒരു ലക്ഷണം മാത്രമാണ്.  ഈ patient ന് എപ്പോഴെങ്കിലും chest pain ഉള്ളതായി പറഞ്ഞിട്ടുണ്ടോ? Chest pain  എന്നില്ല, chest discomfort  എന്ന് പറഞ്ഞിട്ടുണ്ട്. ഈ patient ന് 1.30 P.M ന് cyclopam  നല്കിയത് യുക്തമായ treatment അല്ലേ? അത് ഒരു വേദന സംഹാരി മാത്രമാണ്. ഈ patient ന് ഒരു X-ray നടത്തണമെങ്കിൽ എത്ര സമയം വേണ്ടിവരും? ഞങ്ങൾക്ക്  medical college ൽ 2 minute മതി. അവിടെ  mobile unit ഉണ്ട്. മറ്റ് സ്ഥലങ്ങളിലേത് എനിക്ക് അറിയില്ല. ഈ രോഗിക്ക് വയറുവേദന കുറയാത്തതുകൊണ്ട് വയറിനാണ് X-ray എടുക്കുകയെന്നു പറഞ്ഞാൽ? ശരിയല്ല.  Chestലേയും എടുക്കും.

 In Re-examination PW5 deposed that 3.15A.M ന് collapse ചെയ്ത ഒരു patient ന് 3 മണിക്ക് 97% SPO2 record ചെയ്യപ്പെടാൻ സാധ്യതയുണ്ടോ? record പ്രകാരം 97% എന്നാണ് കാണുന്നത്. 3 മിനിറ്റ് കൊണ്ടും ഒരാൾക്ക് death ആകാം.”

    Here the expert doctor deposed that the  four points mentioned in the District  Level committee are correct ie Ext.A10(a) 1. The method of diagnosis and treatment adopted must be a standard one(2) Reasonable precautions are to be taken(3) Preliminary laboratory tests should be done(4) The treatment /procedure should not be beyond one’s competence.  It is observed that “ if all the above points are covered by the doctor, just making a wrong diagnosis cannot be considered as negligence.  In this case the 3^rd  point mentioned above was not given any consideration by the doctor.  When the patient was complaining of pain continuously for hours, a simple investigation like an X-ray chest or  an Ultrasound  was really indicated here.”

   PW5 expert doctor also deposed that if pain happened repeatedly , the treating doctor should have done investigations like X-ray of abdomen, chest or an Ultra sound scan of the patient.

   1^st OP was examined as DW1.  He has stated that  page 2 Ext.B2(a)യിൽ രോഗിയെ admit ചെയ്യാൻ കാരണം unresponsive gasping എന്ന കാരണത്താൽ ആണ്? അതെ. Gaspingന്ർറെ കാരണം കണ്ടുപിടിക്കാൻ   താങ്കൾ യാതൊരു diagnose test  ഉും നടത്തിയിട്ടില്ല? ഇല്ല. Collapse ചെയ്ത രോഗിയെ രക്ഷിക്കാൻ ശ്രമിക്കാതെ diagnose ചെയ്യാൻ ശ്രമിക്കില്ല.

   If the OP’s version is correct, then it is a gross-negligence on the part of treating doctor.  Because the patient was under observations of 1^st OP from 11.p.m onwards and complaining severe pain many time and  the 1^st OP  then in each time prescribed over phone to administer more  intense of pain  killers to the  patient even  at the time of complaining chest  discomfort.  According to 1^st OP the patient was shifted to ICU by RMO on duty and he came to ICU after collapsing the patient  ie, unresponsive gasping and started CPR.  1^st OP came in ICU and advised to repeat CPR.

  Further deposed in page(5)  ഈ രോഗി ജൂൺ 22 6.53 PM ന് ആണ് casualty യിൽ കൊണ്ടുവന്നത്? ശരിയാണ്. RMO പരിശോധിച്ചു. സാധാരണ ഒരു  gastritis അസുഖം ഒരു RMO ക്ക് manage ചെയ്യാവുന്നതേയുള്ളൂ? ശരിയാണ്. RMO ക്ക് manage ചെയ്യാൻ പറ്റാത്തതുകൊണ്ടാണ് എന്ന് ബോധ്യപ്പെട്ടതുകൊണ്ടാണ്  RMO surgical consultation ന്  refer ചെയ്തത്? ശരിയാണ്. ഈ രോഗിക്ക് 4 മണിക്കൂറും 7മിനിട്ടും കഴിഞ്ഞിട്ടും gastritis കുറയാത്തതിനാലാണ് RMO refer ചെയ്തത് പ്രകാരം surgical consultation എന്ന നിലയിൽ താങ്കളുടെ nurse വിളിപ്പിച്ചത് ? ശരിയാണ്. Further deposed that  1.30 A.M ആണ് (Ext.B1 page -18) breathing difficulty അനുഭവപ്പെട്ടിട്ടും നിങ്ങൾ 3.30നാണ് ആശുപത്രിയിൽ എത്തിയത്? ശരിയാണ്. താങ്കളുടെ ആശുപത്രിയിൽ 61/2 മണിക്കൂർ തുടർച്ചയായ  treatmentനും observationനും ശേഷം രോഗിയുടെ അസഹ്യമായ വയറുവേദന യാതൊരു കുറവും വരാത്തതിനു ശേഷവും താങ്കൾ diagnostic test കൾ നടത്താതിരിക്കാൻ എന്താണ് കാരണം? രോഗിക്ക് അസഹ്യമായ വയറുവേദന ഉണ്ടായിരുന്നില്ല, രോഗി chest pain ഉണ്ട് എന്ന് പറയുന്നില്ല abdominal pain ഉണ്ട് എന്നേ പറയുന്നുള്ളൂ. BPയും  pulse ഉം SPO2 എല്ലാം normal ആയിരുന്നു അതുകൊണ്ടാണ് .1.30 A.M ന് breathing difficulty പറഞ്ഞും എന്തുകൊണ്ടാണ് diagnostic test കൾ നടത്താതിരുന്നത്? ആ സമയത്തും രോഗിയുടെ എല്ലാ parameter ഉം  normal ആയിരുന്നു. Dhanalakshmi hospital NABH  accidental  hospital ആണ്. അവിടെ casualty  യിൽ വന്ന് scanning, X-ray നടത്താനുള്ള facilities ഉണ്ട്? ശരിയാണ്, bed side X-ray facilities ഉം ഉണ്ടായിരുന്നു.

    But PWs 2 to 5 given  expert opinion that if the pain happened recurrent, the treating doctor shall do investigations  on the patient.  Here 1^st OP failed to take any investigations  on the patient.

       The learned counsel for OP submitted certain citation of higher courts.(1) Supreme Court in Jacob Mathew vs State of Punjab(2005)6SCC1, held that “ A simple lack of care, an error of judgment or an accident, is not proof of negligence on the part of professional.  It could not be expected that every physician or surgeon is gifted with extraordinary skills or they can perform miracles.  What is expected of a doctor is whether the procedure adopted by the doctor is acceptable to medical profession.(2) Dr.Moly John vs Lucky Johny(2013 (3) CPR 60) the Kerala State Commission considered the parameter of negligence of doctors and held that what is expected from a doctor is not the standard of treatment which is the highest or lowest but of reasonable standards.(3) The Supreme Court held “It is too much to expect from a doctor to remain on the bed side of the patient throughout his stay in the hospital(Para 26) AIR2022SC204).

   Here we  can see that the  General Surgeon(1^st OP) having ample experience, did not apply his professional skill to the deceased in this case.  There is clear evidence that even the patient was under  the treatment of 1^st OP from 11.P.M on 22/6/2019 to 3.30 A.M and after arriving a provisional diagnosis of acute gastritis on clinical examination at 11 P.M by him, and complaining recurring of Abdominal pain and later chest discomfort, 1^st OP advised to give medicines for gastritis along with pain killers over phone and attend the patient, only at ventilator  when the patient collapsed.  From the actions of 1^st OP, it is very clear that 1^st OP had not apply his minimum skill even to find out final diagnosis of her (deceased) complaint.  From the above stated facts, the decisions submitted by the learned counsel of OP, cannot be considered in this case.

   In the instant case, we are of the opinion that there was negligent actions on the part of the treating doctor, 1^st OP, attributing to the ultimate death of the patient, an untimely death which could have been  avoided by 1^st OP.  The defence contention of the 1^st OP are not found believable.

    On consideration of the case as a whole, we are of the opinion that OPs 1&2 are jointly and severally liable  of gross medical negligence amounting to deficiency of service.  In the result, the complaint is allowed.

  In the complaint, complainants claimed Rs.1 crore for compensation, which was denied by OPs.

   Considering all aspects, although 1^st complainant got job in government service as nurse under the head of dying harness of spouse, it is evident that he was working in gulf country during the time of incident, so loss that income in  their life.  Considering this aspect, and mental agony, loss of companionship and deprivation of love and affection, pain and sufferings of the patient due to the unfair  practice of 1^st opposite party, loss of mother’s love and affection  to 2^nd complainant, we are  allowing a sum of Rs.20,00,000/-(Rupees twenty lakhs only) in total, payable  by opposite parties 1&2 to the  complainants equally.  In addition to that  amount , a  sum of Rs.50,000/- is also awarded as cost of the proceedings.  The aforesaid amount shall be deposited by  the opposite parties 1&2 within a period of 45 days from the date of receipt of the certified copy of this order and the same shall be  released to the 1^st complainant.  In case of default of payment, the awarded amount  Rs.20,00,000/- (Rupees twenty lakhs only)  shall carry interest@9% per annum from the date of this order till realization.  Complainant is at liberty to file EA against opposite parties, as per the provision of  Consumer Protection Act 2019.  With the above direction, complaint stands allowed.

Exts:

A1- Initial Nursing Assessment record

A2-Copy of postmortem certificate

A3- Copy of lawyer notice

A4- Reply notice

A5- Copy of admission discharge form

A6-Last pay certificate

A7-dtd.23/12/19Certified copy of  the statement  of  PW2 furnished to Kannur Traffic Enforcement   

     unite in crime  No.701/19

A8-certified copy of Report of State Level Apex Body

A9-22/8/22 Certified copy of statement of PW5 furnished to Kannur Town police

A10-Copy of FIR

A10(a)-copy of Expert panel Report

A10(b)-copy of Expert opinion

A11-copy of judgment in CC/296/16 of CDRC,Kannur

B1-  Case sheet

B2-ICU register

B2(a) Relevant page in Ext.B2 page No.13

PW1- Dinesh Chandran- 1st  Complainant

PW2.Dr.S.Gopalakrishna Pillai- witness of PW1

PW3-Dr.Jose G.Dicruse-do-

PW4-Dr.Preetha.P.P-  do-

PW5-Dr.Sreejayan.M.P    -do-

DW1- Dr.C.P.Visharathan  - 1st OP

Sd/                                                                Sd/                                               Sd/

PRESIDENT                                             MEMBER                                   MEMBER

Ravi Susha                                       Molykutty Mathew                                    Sajeesh K.P

eva                                                                                 /Forwarded by Order/

                                                                            ASSISTANT REGISTRAR