KERALA STATE CONSUMER DISPUTES REDRESSLA COMMISSION VAZHUTHACAD, THIRUVANANTHAPURAM

OP.50/2001

JUDGMENT DATED: 5..11..2011

PRESENT

JUSTICE SRI.K.R.UDAYABHANU : PRESIDENT

SRI.S.CHANDRAMOHAN NAIR    : MEMBER

Muthu vijayan(Minor now aged 4 years rep.by  : APPELLANT

Guardian Ajayan aged 42 years

S/o Krishnan Nair,

Pullampallil Puthenveedu,

Karimulackal, Komallur.

(By Adv.N.Suresh)

1.De.Viswanathan, M.S.                                     :OPPOSITE PARTIES

    St.Thomas Mission Hospital, Kattanam,

2. St.Thomas Mission Hospital, Kattanam

    Rep by the Administrator,

    St.Thomas Mission Hospital, Kattanam,

(By Adv.David Koshy)

JUDGMENT

JUSTICE SRI.K.R.UDAYABHANU : PRESIDENT

          The complaint is filed by the father on behalf of the minor child aged 4 years.  The allegations in the complaint are as follows:- On 5.5.99 at about 5PM the minor child was admitted in the 2^nd opposite party hospital  for burn injuries.  The 1^st opposite party doctor who examined the child had assured that everything will be all right within a few days.  The parents of the minor child were told that the  1^st opposite party doctor was a Surgery Professor of  Medical College Hospital, Calicut and that the child will be provided  with the best available treatment.  On the third day of admission blackening on the burnt portion of the minor child was noticed by the complainant and the same was reported to the doctor who told that it is a sign of healing.  But the 5^th day morning at around 10⁰ clock the child was crying in severe pain and had shivering and her eye-balls were rolling.  The complainant informed to doctors as to the condition and  she was taken to the operation theatre.  At about 5PM she was shifted to the post operative room.  After some time when the complainant went to the post operative room he saw the minor  tied to the strecture and was totally immobilized.  1^st opposite party doctor was not available in the hospital and the complainant had insisted for an immediate discharge.  Opposite parties insisted for payment of the entire bills.  Thereafter the child was discharged and rushed to Pushpagiri hospital, Thiruvalla.  She was treated at Pushpagiri hospital for 5 days.  As there was no improvement  she was referred to SAT hospital, Thiruvananthapuram.  At SAT hospital she was an inpatient from 15.5.99 to 28.6.99 and from 29.9.99 to 9.10.99 and from 19.1.2000 to 31.1.2000.  The right hand of the child is totally disabled.  At the time of examination of the child at Pushpagiri hospital and SAT hospital  it was found that she had developed  septicemia.  Allegedly on account of the negligence in the treatment initially provided to the child at the opposite party hospital that she developed septicemia.  It is alleged that 1st opposite party doctor was neither qualified nor experienced to provide the required medical aid.  Two fingers from the right hand of the minor child had to be removed and her right hand is twisted and is incapable of any effective movements.  The disability and disfigurement has rendered her gloomy and she is abstaining from mingling with other children.  The same would seriously affect her education and employment marital prospects etc.  Always a bystander is needed to take care of the child.  The above child is the only child of her parents.  The opposite party/hospital was not having the necessary  infrastructure to handle the situations of such a nature.  The complainant has claimed a sum of Rs.12lakhs as compensation.

          2. The 1^st opposite party doctor has filed version denying the allegations.  It was stated that child is aged 2 years at the time of admission.  On examination it was found that she was having 30% burn injuries.  The baby was provided with all treatment required for  managing the acute burn injury.  1^st opposite party had taken all care and caution to save the child.  It is denied that he had assured that the child will be all right within a few days.  No such assurance can be given with respect to a 2 year old child with 30% burn injuries.  The 1^st opposite party was Professor of Surgery at Medical College hospital, Calicut.  The 1^st opposite party and all medical and para medical staff of the hospital had done everything  known to medical science and available in that part of the State to treat the child.  The child was treated in strict compliance with standard of care and caution expected from the medical and para medical staff of the opposite party hospital.  The dangerous situation of the child with 30% burn injuries was made clear to the bystanders.  Probable consequences of the burn injury that may result was also explained. The allegations in the complaint as to the condition of the patient on the 5^th day after admission is denied.  The child might have been taken for dressing and due to the injuries the child might have cried due to pain.   The child was shown to pediatrician as instructed by the doctor.  The child was on rylestube feeding and many drugs were administered through dripline IV.  The child was later discharged with reference letter to Medical College Hospital, Alleppey.  It is contended that the doctors attached to Pushpagiri Hospital, Thiruvalla and SAT hospital, Thiurvananthapuram who treated the child are necessary parties.  The alleged disability to the right hand of the child  is not due to any carelessness on the part of the opposite party.  The child was admitted at Pushpagiri hospital from 10.5.99 to 15.5.99 inspite of advice given by the 1^st opposite party to take the child to Medical College Hospital, Alleppey.  The patient did not have septicemia or any signs of the same while she was in the opposite party hospital.  The 1^st opposite party is a well qualified, well experienced and skilled Surgeon.  It is only for the purpose of specialized treatment for conducting plastic surgery etc  the child was referred to Medical college Hospital Alleppey. Had she been admitted as directed at Medical college Hospital and provided specialized treatment such as plastic surgery  the disabilities due to the burn injuries could have been cured at least to a certain extent.  Due to mal nutrition the child’s  resistance was also below average.  It is understood that the child and the parents came from poor financial background.  Had she been taken to Medical College Hospital, Aleppey as suggested she would not have lost 2 fingers.  Response to the treatment was comparatively slow because of the intensity of burn injuries and because of the mal nutrition of the child.

          3. The 2^nd opposite party hospital has also filed version containing the same averments as in the version of 1^st opposite party.

          4. The evidence adduced consisted of the testimony of PWs 1 and 2, RW1; Exts.A1 to A4(b), A5 and B1 and B2, X1 as well as interrogatories and reply to the same from Dr.Hema, Professor, SAT Hospital at the instance of the complainant and from Dr. Sivaramakrishna Pillai, Director of Parabrahma Speciality Hospital, Ochira, Kollam at the instance of the opposite parties.

          5. PW1 the father of the minor who filed the complaint has testified as to the incident that on 5. 5.99 at about 5PM his daughter aged 2 years and 10 months happened to fall into a   pot of boiled  preparation meant for feeding cattle which was kept in the kitchen floor.  She was immediately taken to the 2^nd opposite party hospital wherein she was treated  the 1^st opposite party, Surgeon who assured that the best treatment available will be provided to the child and also told that he has been a Surgery Professor at Medical College Hospital, Calicut.  According to him on the 3^rd day of admission, a blackening on the burnt portion of the body was noticed and that he  informed the same to 2^nd opposite party who  assured that the blackening is quite normal and that it is a sign of healing of the burns.  According to him on the 5^th day morning around 10^o clock his daughter was found crying loudly and shivering and her eye balls were rolling.  When he contacted the 1^st opposite party/surgeon she was taken to the operation theatre and at about 5 ^o clock she was shifted post operative room.  According to him when he entered the post operative room to see the child her both hands and legs were tied to the strecture and was totally immobilized.  He contacted 1^st opposite party and was told that his duty time is over and directed to report the matter to the duty doctor.  The complainant insisted for discharge which was done only after paying the bills.  It is there after the reference letter was given to Pushpagiri Hospital, Thiruvalla.  Soon she was taken to Pushpagiri Hospital wherein the condition was identified  as septicemia.  At Pushpagiri Hospital every attempt was made to save the child there was no improvement inspite of their timely treatment and she was referred to SAT Hospital, Thiruvananthapuram wherein she underwent prolonged treatment and inspite of the same she was lost two fingers of the right hand.  According to him it was the careless and negligent treatment provided by opposite parties in the initial stages that resulted in septicemia and the complications that resulted in the disfigurement.  Right now her right hand is immobilized and the disability will affect her life throughout.  It is alleged that the 1^st opposite party was neither qualified nor   experienced to treat such cases.  The 2^nd opposite party hospital was not having any specialized burn unit and skilled para medical staff and properly qualified and experienced doctors. The right hand of the child is twisted and without effective movements.  He is also produced the hospital bills and treatment records.  In the cross examination he has stated that after admitting  at the opposite party hospital the burnt portion was covered by bandage and  drip was administered.  He has also stated that the child was admitted in room No.13, payward and close relatives and others used to visit the child.  She was discharged at about 7PM on 10.5.99.  It was suggested that it was the ingredients in the brew meant for the cow that caused the infection.  It was also suggested that the infection developed as there used to be  continuous visitors to see the child who was having 30% burns.

          6. PW2 the plastic surgeon who treated the child at Pushpagiri hospital, Thiruvalla  has stated that at the time of admission the child had 30% of deep infected burns over right upper limb, back and buttock.  The child had toxic appearance and tachypnea ie, increased respiratory rate.  There was abdominal distention and reduced bowel sounds and these features are suggestive of  septecimia .  She was treated with antibiotics, blood transfusion and intravenous albumin  and wound care.  Irrespective of the attention provided the child’s condition deteriorated and after discussing with pediatrician and the father of the child she was referred to SAT Hospital, Thiruvananthapuram.  He has also proved the treatment records of Pushpagiri hospital and the referral letter ie Ext.A4 and A5 respectively.  He has stated that the deformities can result due to burns and septicemia.  The burns can produce deformity due to loss of normal tissue and  excess fibrous tissue formation.  Septicemia can lead to disseminated embolism and tissue loss.  Septicemia alone cannot cause deformity.  He has also stated that septicemia can be the result of unhygienic condition and that if a patient with 30^O burn injuries is  treated in a hospital without burn unit the  cause of chance of  septicemia is on the higher side. A burn unit will be provided by facilities for isolation, specialized doctor and nurses in burn treatment and other supportive measures like  blood bank and advanced  monitoring devices.  An unhygienic condition can produce septicemia if there is a wound or burn.  This is one of the reason why the patient is kept in isolation.  He has also mentioned the standard treatment for burns to the child that apart from administration of IV fluid at stipulation quantities and stipulated hours, parenteral (through veins) antibiotics preferably of a  higher group like ampicillion, cloxocillin or cepholoporine and  intra venous H2 antagonist like ranitidine  and oral anti acidic agents and wound care by cleaning with saline and modern method of dressing in collagen sheets is required.  The above should be added a topical antibiotic crèmes. For burns  above 10% deep 3^rd degree one unit of blood for every 10%   has to be given.  The same should be supplemented with IV fluids and nutritional support.  He has stated that in the case of the child  involved the standard treatment was not given at the opposite party hospital.  Now a days crystalline penicillin is not advised because the  spectrum of bacterial coverage is only gram positive and also reactions to penicillin has also to be considered   when the drug is used .  Even if the sensitivity rate is negative there are reports of developing reactions to penicillin. In Ext.A4(b) ie, reference letter from 2^nd opposite party hospital administration of crystalline penicillin is mentioned. He has also stated that no fee was charges for the treatment of the patient at Pushpagiri hospital.  He has stated  if there is 30% deep burns there will be residential deformities. The deformities can be due to burns alone or a combination of burns with septicemiaand septic embolism.  He has also stated that the entire deformities can not be cured completely by plastic surgery but it can be reduced to a certain extent.  According to him applying modern micro vascular   surgery technics if a finger is lost  the same can be  replaced by transferring a toe from the leg and the expenses at the time would amounting to about Rs.50,000/-(he was examined  on 7.8.03).  In the cross examination he has admitted that the particular antibiotics administered at Pushpagiri hospital is not evident from Ext.A4 treatment record.  The investigation reports are also not seen in Ext.A4.  The case sheet of inpatient treatment was not seen produced.  On 10.5.99  immediately after the patient  was brought the casualty  medical officer   has transferred the patient to the plastic surgery department at Pushpagiri Hospital.  He has admitted that the ingredients of the preparation meant for cows may for  possibly have its adverse effect so far as injuries are concerned.  He has stated amikasin which is administered at the opposite party hospital is not advisable to a patient with acute phase of burns because it is a kidney toxic drug. Amikasin was administered from 5.5.99 to 7.5.99 at the opposite party hospital. He has admitted that the urine output was adequate when the child was brought to the Pushpagiri Hospital. It was suggested to him that that second and third degree burn involving more than 10% of the body surface area in patients younger than 10 or older than 50 years of age is fatal.  He had admitted that such injury is always dangerous and fatal to a child.  He has also admitted in the cross examination that there will be gastro intestinal change due to burn injury which may result in vomiting and paralysis of intestine. Immunity will be suppressed and the patient will be prone to infection.  Oral antibiotics can produce diarreah .  He has denied the suggestion that it was the treatment provided at Pushpagiri Hospital that deteriorated the condition of the patient. It was brought out that he is having MCH degree in Plastic Surgery from Kottayam Medical College Hospital and that he obtained the same in 1995.

          7. RW1 is the casualty duty doctor at the opposite party hospital.  His qualification is MBBS.  He has stated that the 1^st opposite party doctor is employed in Nepal.  RW1 was on casualty duty on 10.5.99.  On 5.5.99 the child was seen by 1^st opposite party Surgeon and that it is mentioned in the case sheet that child was having 30% burn injury.  It is clear from the case sheet(Ext.B1) that IV fluids have been administered with IV crystalline penicillin, 5 lac unit 6^th hourly, IV amikasin 100mg 10^th hourly. Silver sulphadicine was used to prevent bacterial infection. Urine was collected inserting a foleys catheter in the urethra of the patient.  He has stated that the patient was admitted in post operative unit and that the same is sterile room. The patient was in the post operative  unit  from 5.5.99 to 8.9.99.  No visitors had been permitted in the post  operative unit.  According to him as the burn injuries were also in  the  buttocks the chance of  bacterial infection from stool getting into burn site is possible.  According to him the standard treatment was given to the child.  According to him on 7.5.99 the patient was having fever for which paracetamol syrup was administered. On 7.5.99 all antibiotics through IV route has been stopped and syrup ampiclox 5ml 6 hourly was started.  According to him the same indicated that the child was responding the treatment given on 5.5.99 and 6.5.99.  On 9.5.99 at 10.35 pm the patient had  itching on the burn site  and bleeding while itching  and the necessary medicines to induce  sleep was given. On 10.5.99 at 7am she had loose stools 3 times, vomiting once.  The same can be due to oral antibiotic treatment.  Injection Perinorm
½ml  intra vascular was administered and the child was referred to pediatrician at 1.20pm. On 10.5.99 the child had high fever 103.8^OF This was treated with paracetamol. At that point Surgeon/opposite party No. 1 decided to refer the patient for better management to Medical College Hospital, Alleppey.  According to him the father of the patient insisted for referral letter to Pushpagiri Hospital, Thiurvalla because of  proximity from his residence.  Hence the same was issued.  He has also admitted that the 2^nd and 3^rd degree burn injuries   to the extent of 10% to children below 10 years and adults above 50 years of age is fatal.  According to him initial treatment provided was successful. He has admitted that he has not treated  the child at the opposite party hospital. According to him there was no separate specialized unit for burn injuries in Alleppey Medical College Hospital. In the opposite party hospital also there is no separate burn unit.

          8. Ext.A1 are the bills of purchase of medicines and also the bill for treatment at the opposite party hospital.  Ext.A2 is the surgical short case history from surgical pediatric unit of SAT hospital, Trivandrum wherein it is mentioned that the child was having 3^rd degree burns involving the whole back, buttocks, right upper limb and right side of abdomen. It is seen from therein that the child was inpatient  from 15.5.99 to 28.6.99 ie 44 days.  She underwent procedure for release of contractures a number of  times.  She was again inpatient at SAT hospital from 29.9.99 to 9.10.99 ie, 11 days during which period she underwent skin grafting and also procedures for release of  contractures.  She was again inpatient for 13 days from 19.1.2000 to 31.1.2000 in which period she was treated for  post burn contractures and underwent skin grafting.  Ext.A3 are the photographs of the child which would show that her right hand palm and forehand portion distorted.  The child was seen by this Commission also.  The right hand palm appeared totally disfigured and virtually of no use.  Ext.A4 is a treatment  record of Pushpagiri Hospital in which Ext.A4(b) reference letter from the 2^nd opposite party hospital is also affixed.  It is mentioned therein that the patient is discharged as the bystanders demanded discharge.  Therein also 30% burn is noted and the treatment provided is also mentioned in short.  Ext.A4 is mentioned as OP record wherein the date of admission is noted as 10.5.99 and date of discharge is mentioned as 15.5.99.  30% burn is also noted at plastic surgery department.  It is also mentioned that burns are infected at the time of admission. It is also mentioned  that there were features of septicemia, abdominal distention and low  bowel sounds and the patient was toxic from confused stage and  tachipnea plus.  On 15.5.99 the time of discharge  noted as 1pm.  In the discharge note it is mentioned that the condition of the patient had deteriorated and that after consultation with the pediatrician she was referred to a major centre.  Ext.A5 is the reference letter issued by PW2, Plastic Surgeon to SAT hospital wherein it is mentioned that the child at the time of admission was having 30% deep burn injuries with features of septicemia and that there was abdominal destination raised respiratory rate.  The burns were of 30 degree and infected she was administered with parenteral antibiotic albumin and blood transfusion and that the response is poor. 

          9. Ext.B1 is the case sheet of the 2^nd opposite party hospital wherein treatment as mentioned by RW1 is noted in the case sheet.  Ext.B2 is a prescription at the time the patient was examined at casualty on 5.5.99.  The time is mentioned 4.45pm and the extent of burns is mentioned as 30 degree.

          10. The opposite parties obtained answers to interrogatories from Dr. Sivaramakrishna Pillai, Director of Parabrahma Speciality Hospital, Ochira, Kollam a private hospital.  He is specialized in General Surgery and  retired from the post of Director of Insurance, Medical  service in Kerala.  He has stated that none of the major hospitals in Kerala has a burn unit with specialized surgeons and specialized nurses and independent department and that all major  hospitals are attending burn cases.  According to him the services of qualified and experienced general surgeon and that of qualified and experienced nurses will be sufficient to handle burn cases.  According to  him specialized burn units are not essential to treat burn cases.   The IC units and post operative units are free from infection. The standard treatment in such cases is correction of fluid loss by parenteral fluid therapy, giving sedation to prevent shock and relieve pain and covering the burnt area with antiseptic ointment and administering antibiotics to prevent secondary infection and for rapid healing of the burnt surface.  The presence of mixture of coconut oil cake and tamarind seeds in water may cause sepsis on a child patient with 30% 3^rd degree burn injury.  He has also mentioned that for replenishing proteins in case of reduced hemoglobin contents on a patient plasma and blood transfusion will be advisable.  According to him crystalline penicillin is a common drug generally administered. He has also stated that fever on such patients is likely to be caused due to dehydration, secondary infection, urinary infection and chest infection.

          11. Dr Hema, Professor , SAT hospital of Medical College, Thiruvananthapuram who treated the child has answered interrogatories submitted at the instance of the complainant. She has also stated that the child was admitted  with infected burns and that the   extent of burns were 30 % and at the time of admission the child was  sick and toxic and that she was in a critical stage.  She has also stated that deformities and disabilities is the result of burn injuries.  The infected burns is the result of infection of the raw wounds      by micro organisms and that chances of infection is higher in a person with 30% burns treated in a general ward. Both the doctors have answered the interrogatories in the form of affidavit.

          12. Ext.X1 is the disability certificate issued by Medical Board consisting of seven doctors of Medical College Hospital, Thiruvananthapuram dated 24.1.08 (incident was on 5.5.99).  It is mentioned in Ext.X1 that the child is suffering from post burn contracture with non functional hand (forearm, wrist and hand )-on right side.  The deformities noted are: the wrist fixed  in palmar flexion and ulnar deviation on right side; loss of 2^nd and 3^rd at PIP level on right side; extensive ugly scar, involving forearm, elbow hand and arm segments. It is also mentioned that she has got a permanent disability of 40%.

          13. The 1^st opposite party, the surgeon who treated the child at the 2^nd opposite party hospital has not testified.

          14. As seen from the records the child has sustained 3^rd degree burns which is full thickens burns and the extent is 30%.  The statement of PW1 that she was discharged at about 7pm on 10.5.99 stands not disputed.  The time of discharge is not mentioned in Ext.B1 case sheet.  The evidence of PW2, Plastic Surgeon who treated the child at Pushpagiri Hospital, Thiruvalla that the child was having infected burns and features of septicemia stands not disputed.  The case of PW1  the complainant that it was at the insistence of PW1 that Ext.A4(b) reference letter was issued. It is specifically mentioned therein that the child is discharged as the byestandars demanded discharge.  Evidently the 2^nd opposite party hospital is not having the facilities of plastic surgery etc which is required in certain burn cases like that of the child involved herein.  The case of PW1 that there are used to be visitors to the child stands not disputed and further it is even suggested in the cross examination of PW1 that infection was on account of frequency of visitors which ought to have been totally forbidden by the authorities of the opposite party hospital.  Further  RW1 has stated that from 5.5.99 to 8.5.99 she was in the post operative unit.   Possibly thereafter she was in the  pay ward room.  PW1 has stated that the child was in room No.13.  The same has not been disputed.  PW1 has also stated that there was dark discolouration of the burnt areas on the 3^rd day. Discolouration of wound is a medical sign of wound infection(David C Sabiston, J.R, Text Book of Surgery) 13^th edition page 226).  Further it is admitted as seen from the suggestion in the cross examination of PW2 that the 2^nd and 3^rd degree burns involving morethan 10% to the body surface in a patient younger than 10 years or elder than 50 years is fatal relying on Sabiston’s Text Book of Surgery(supra). RW1 who testified on behalf of the opposite parties has also stated that burn injuries to the extent of 10% is fatal for a child aged less 10 years.  The authorities on the point is that in case of 3^rd degree burns the burns in infants and elderly are major burns and these burns typically require referral to a specialised  burn centre.  Septicemia in the children are more for such injuries susceptible .  The same is bacterial infection of blood.  Major burns are those that affect more than 20% child’s body, or a 3^rd degree burn of more than 10% of body surface area which are most serious and should be treated in a specialized burn unit of the hospital.  Children with such burn injuries if the hospital initially receiving the patient does not have qualified personal or equipments ought to refer to a higher centre. Further more in the instant case we find that PW2, Plastic Surgeon who treated the child at Pushpagiri Hospital has asserted that the treatment provided to the child at the opposite party hospital was not the standard treatment that ought to have been given to a patient with such burn injuries.  It has also came out that despite the fact the child was having features of septicemia  the child was retained at the opposite party hospital that  resulted in a rendering condition of the patient critical. As evident from the treatment records the child underwent prolonged treatment and multiple procedures for contracture  release and  skin grafting and yet she lost 2 fingers of the right hand and the hand  in distorted condition and she is having 40% disability as seen from Ext.X1 disability certificate.  Although the appearance of the features of septicemia is not having direct nexus with the deformity as is mentioned by the PW2, Plastic Surgeon  septicemia associated with  serious burns can result in tissue loss and delayed healing.  Evidently facilities  for blood transfusion/blood bank, skin grafting and sterile isolated treatment room is required for treating serious burn cases which the opposite party hospital was not having. The answer to the
interrogatories by Dr. Sivaramakrishna Pillai mentioning that the services of a General surgeon and a post operative room facility is sufficient is not supported by the authorities produced.  Never delay treatment to a burn victim is stressed in the relevant text books.  We find that the records and the evidence clearly indicate that the child ought to have been referred to a higher centre soon after administration of initial treatment.  In this regard we find that there is serious negligence and lapses on the part of the opposite parties.

          15. So far as  the compensation is concerned indisputably the girl has sustained serious permanent disability which the Medical Board had assessed as 40%.  All the same there is no full proof evidence to hold that the distortion and disability as well as disfigurement was  exclusively on account of the negligence/lapses on the part of the opposite parties.  As already noted above delay to refer to a  higher centre  and  septicemia  has also contributed to the gravity of he condition.  The child would have to undergo further costly treatments to reduce the extent of disfigurement and disability.  Taking into account the entire circumstances we find that a sum of Rs.3,00,000/- would be  reasonable  compensation.  Complainant will also be entitled for interest at 7% per annum from the date of complaint ie 3..5..2001. The complainant will also be entitled for cost of Rs.10,000/-.  The opposite parties 1 and 2 would be jointly and severally liable to pay the amount.  The amounts are to be paid within three months from the date of receipt of this order failing which the complainant will be entitled for the interest at 12% from the date of  this order ie 5.11.2011.

          In the result the appeal is allowed as above.

                   JUSTICE K.R.UDAYABHANU       : PRESIDENT

                   S.CHANDRAMOHAN NAIR           : MEMBER

Ps

APPENDIX

Complainants Witness:-

PW1 – Vijayan Nair

PW2 – Dr.P.R.Venugopal, Plastic Surgeon

Opposite parties Witness:-

RW1 –  Paulson.E.C

Complainants Exibits:-

A1 – Bills

A2 – Original surgical history sheets(3 in No.)

A 3 – Photographs

A 4 – OP record, Pushpagiri hospital

A4(b) –  Reference letter from 2^nd opposite party Hospital to Pushpagiri 

              Hospital.

A 5 –  Referal letter         

Opposite party’s Exibits:-

B1 -  Inpatient chart of St.Thomas Mission Hospital, Kattanam

B 2- Outpatient record of St.Thomas Mission Hospital, Kattanam

Court Exhibit

X1  - Disability certificate

                   JUSTICE K.R.UDAYABHANU   : PRESIDENT

                   S.CHANDRAMOHAN NAIR       : MEMBER

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