DOF.11.04.2005
DOO.26.08.2011
IN THE CONSUMER DISPUTES REDRESSAL FORUM, KANNUR
Present: Sri.K.Gopalan : President
Smt.K.P.Preethakumari : Member
Smt.M.D.Jessy : Member
Dated this, the 26th day of August 2011
CC.96 /2005
Neelima R.,
Karthika
North Manakkatt,
Karivellur .P.O, Complainant
1. Managing Director,
Dhanalakshmi Hospital,
Kannur 2.
2. Dr.Jubeirieth.V.K.
Dhanalakshmi Hospital,
Kannur 2. Opposite parties
3.Dr.Sameer.S.,
Dhanalakshmi Hospital,
Kannur 2.
(Rep. by Adv.Mahamood for Ops 1 to 3)
O R D E R
Sri.K.Gopalan, President
This is a complaint filed under section 12 of consumer protection Act for an order directing the opposite parties to pay an amount of `5, 00,000 as compensation and to pay the cost of this proceedings.
The case set up by the complainant in brief is as follows: - Complainant became pregnant at Bhopal and had consultation with gynecology there. During her monthly check up no abnormality or uneasiness were detected. After returning home on her 7th month she started consultation with second opposite party she had five review checkups with the 2nd opposite party. No signs of unusualities reported till 2.12.04. On 7.12.04 she rushed to hospital since she felt movement and after consultation 2nd opposite party opined she is perfectly alright for normal pregnancy within two or three days. When complainant repeated her uneasiness 2nd opposite party prescribed a scan test and referred to the third opposite party but not even cared to examine her clinically. Scanning was done and after perusal of scan report dated 7.12.04 opposite parties 2 and 3 expressed their full satisfaction. On 9.12.04 she was admitted in 1st opposite party’s hospital following travail. On examination 2nd opposite party suggested emergency LSCS. 2nd opposite party conducted LSCS and she delivered a female baby at 12.08 P.M. Nurses handed over the baby to parents. When indication of some uneasiness felt baby was taken to the labour room. By 6 p.m the condition became worse and placed in incubator. The child reported dead on the next day. According to 2nd opposite party the cause of death is chronic placental insufficiency and intrauterine hypoxic. Opposite parties further said that Echocardiography reported severe persistent pulmonary hypertension and placenta had a large intra placental haemangiame which was proven by biopsy taken during the course of LSCS. 2nd opposite party could not notice unusual conditions in placenta since there was no effective clinical examination. She failed to refer the patient for a CT scan examination in time. More over, handing over the baby to relatives and keeping the baby with them has also caused reason for the death of the child. Likewise 2nd opposite party referred the complainant to a Radiologist who is having no knowledge about the Radiology and imaging. 3rd opposite party shown gross negligence. 1st opposite party is bound to provide proper treatment through opposite parties 2 and 3. The death was a shock to entire family. Lawyer notice was sent on 8.2.05. It was replied with one sentence without substance denying allegations of negligence and deficiency in service. Complainant and family suffered intolerable agony and pain. Hence this complaint.
Pursuant to the notice opposite parties appeared and filed version. 1st opposite party contended as follows: Department of obstetrics is headed by Dr.Jubaireth, M.D, DGODNB, who has more than 20 years service in her speciality out of which 15 years were in the Kerala Govt. Health services. Dr.Sameer passed his MBBS from Bangalore Medical College in the year 2000 with first class and DMRD 2004 with 60% marks. He joined as a specialist in Radio diagnosis. He became a popular Sonologist within a short span of time. The Ultra sound scanner in the hospital is one of the latest equipment. U.S Scan done at Bhopal on 19.7.04 was reported normal. Subsequent antenatal checks were done on 27.10.04, 19.11.04, 2.12.04 and 7.12.04. On 7.12.04 scanning was done and reported a single live intrauterine gestatio0n caesarian operation was done on Neelima on 9.12.04 as the fetus showed signs of distress. Placental haemongioma which was noted by Dr.Jubaireth during caesarian was only on incidental finding. If it was the real cause for the baby’s death the baby would not have grown to the size 2.4 kg. as noted in scanning. The baby died on 10.12.04 due to sever pulmonary hypertension. Pulmonary Hypertension was diagnosed by Dr.Vijayakumar M.D, DM(Cardio) after doing Echocardiography. Opposite parties followed accepted norms and protocol in the diagnosis and treatment of the patient. There was no negligence or deficiency in service. Hence to dismiss the complaint.
2nd opposite party filed version separately stating which in brief as follows: The complainant first came on 6.10.04. Her expected date of confinement was on 13.12.04. She had regular antenatal check up at Bhopal. 2nd opposite party checked previous ultra sonography and blood investigation she had a normal ultra sonography on 19.7.04 at Bhopal and was found therein to be having 19 weeks pregnancy with no congenital anomaly or placental abnormalities. The patient came for antenatal check up on 27.10.04, 19.11.04, 2.12.04 and 7.12.04. She came with complaints of decreased fetal movements on 7.12.04. On examination uterine fundus corresponded to 38 weeks size, the baby was in longitudinal lie, with cephalic presentation, fetal heart rate-144/mt. The second opposite party sent for USG for fetal biophysical profile to assess fetal well being. Emergency USG report came to show a live fetus in longitudinal lie, cephalic presentation of 37 weeks and 5 days. Estimated Baby weight was 3042 + 456 gms and BPP 8/8. As the patient and her relatives were not willing for admission, they went back home. Again on 9.12.04 at 1.00 am, patient came with backache. The patient was seen by Dr.Sindhu, RMO, O/E uterus was full terms not acting, head fixed, FHS 140/Mt, BP 120/70 mm Hg, P/V Cx 70% effaced, Os admits 1 finger, head at -2 Station, Pelvis Normal. She informed the second opposite party about the case and the second opposite party advised to admit her and to give a soap and water enema. After monitoring for some time she was sent to her room. The2nd opposite party examined the patient at 8.00 a.m on 9.12.04. On examination, uterus was acting mildly, FH 140/mt, P/V-cervix fully effaced, membrane + head at -2 stations, pelvis normal. As there was no sufficient progress and the liquor was meconium stained, operation was decided and informed the relatives. Emergency LSCS was done and delivered a female baby at 12.08p.m, weight 2.4 kgs. Baby cried soon after birth. Soon after delivery baby was handed over to Dr.Ranjith Lal, Pediatrician of the hospital who examined the baby and afterwards baby was given to the relatives. In the evening baby developed distress and was admitted in NICU. Baby was seen by cardiologist. Cardiography was done and diagnosed as severe persistent pulmonary hypertension. In spite of ventilatory support and vigorous treatment, baby could not be saved. Persistent pulmonary hypertension cannot be detected before birth. There is no negligence on the part of 2nd opposite party. Hence to dismiss the complaint.
3rd opposite party also filed version separately. The contentions of 3rd opposite party in brief are as follows: 3rd opposite party was asked to do an obstetric ultra sound scan on 7.12.04 and to assess the fetal biophysical profile. The assessment revealed a normal biophysical profile score (BPP). Neelima was scanned on 7.12.04 and the fetus had a normal BPP score at that time. Mrs. Neelima developed labour pain on 8.12.04 at 10 p.m and was duly admitted. Meconium aspiration was suspected clinically on 9.12.04 and was advised LSCS. LSCS was performed and female baby delivered. Baby cried immediately after birth. The condition of the baby deteriorated and died on 10.12.04 at 2 PM due to severe persistent pulmonary hypertension, which was diagnosed on echocardiography by the cardiologist. This is a serious condition with a very high perinatal mortality rate. This condition is possible to diagnose only after the baby is born as the fetal lungs do not breathe air in the mother’s womb and the fetal lungs are put to work only after birth. In this condition, the fetal lungs and circulatory system persist in to postnatal life making thereby living incompatible after birth. Placental Hemangioma which was seen during the LSCS and later proved by biopsy can be considered as an incidental finding only. Placental hemangioma also known as chriongiomas is very rare tumors of placenta. Placental hemangioma would have been there since first trimester and was not diagnosed earlier even at Bhopal when she was consulting most part of her pregnancy( 7 months).It reflects the rarity of the lesion and difficulty in diagnosing the condition on routine obstetric scans. Most of the chorioangiomas have no clinical significance. However, rarely large chorio angiomas may cause complications like polyhydromnious fetal hydrops which were not present in the baby of Mrs.Neelima. So a condition of chorio - angioma having caused death is highly unlikely and even if it was diagnosed on the scan done on 7.12.04 the outcome of the baby would not have altered in 48 hours. Reasonable appropriate and adequate care and knowledge were delivered to Mrs.Neelima and her baby.
On the above pleadings the following issues have been taken for consideration.
1. Whether there is any deficiency on the part of opposite
parties?
2. Whether the complainant is entitled for the relief as
prayed in the complaint?
3. Relief and cost.
The evidence consists of the oral testimony of PW1, DW1 Exts. A1 to A5, B1, B2, B2 (a) and B3.
Issue Nos.1 to 3
Admittedly the complainant Mrs.Neelima approached 2nd opposite party for antenatal check up on 27.10.04, 19.11.04, 12.12.04 and 7.12.04. Complainant was admitted in the hospital on 9.12.04. Emergency LSCS (Caesarean) was done and delivered a female baby. Pediatrician examined the baby and afterwards handed over to relatives. Baby developed distress in the evening and was admitted in NICU. Baby was seen by cardiologist; Echocardiography was done and diagnosed as severe persistent pulmonary hypertension. Baby could not be saved with treatment provided.
The allegation of the complainant is that she had started her treatment with 2nd opposite party and had check up as mentioned above. On 7.12.04 complainant rushed to 2nd opposite party at the hospital of 1st opposite party. Complainant was seen by 2nd opposite party and opined that the complainant is perfectly alright for a normal pregnancy within two or three days. She stated to the complainant and her bystander that carrying ladies, who wants to monthly check up are waiting for her and advised that if the complainant feels any uneasiness it can be ascertained by subjecting to a C.T.Scan examination. When she repeated her uneasiness opposite party prescribed a scan test to her and referred to 3rd opposite party. 2nd opposite party did not care to examine her. Even after the perusal of scan report opposite parties 2 and 3 stated that there was nothing abnormal. On 9.12.04 she had been admitted following travail. 2nd opposite party examined the patient and suggested an emergency LSCS. As such complainant underwent LSCS and gave birth a female baby at 12.08. At about 2 p.m nurses handed over the baby to the complainant’s parents, saying to report incase of any uneasiness. When some uneasiness noticed baby was taken to labour room. By 6 p.m condition became too bad and entered into incubator. On 10.12.04 at 2 p.m child reported dead. Baby was died due to the sheer negligence of opposite parties. The mass in placenta and placental insufficiency even before sending the complainant to C.T scan. The above said condition in placenta could have ascertained by effective clinical examination. So also the handing over the child to parents and keeping the baby with them without telling about the complications which was seen by 2nd opposite party during LSCS has caused the death of child. Likewise 2nd opposite party referred complainant to a Radiologist who is having no knowledge about the radiology and imaging. Gross negligence has shown by the third opposite party. It is the bounded duty of 1st opposite arty to make assure proper treatment.
Opposite parties on the other hand contended that placental abnormality cannot be detected by clinical examination or check up. The complainant was referred for ultra sound scan and not C.T scan. The ultra sound scan did not mention anything abnormal. Hence 2nd opposite party could not be blamed for not having detected the placental anomaly before delivery. Even if placental abnormality was detected before delivery, it would not have made difference in treatment. No damages were caused by alleged non detection of the placental abnormality before delivery. There was no complication for the baby which was detected at delivery. The only abnormality was a large placental mass. Haemangioma in the placenta was found by histopathology examination. The fact of large placenta and need of histopathology examination was told to the relatives. On 7.12.04 2nd opposite party had advised the complainant to get admitted for further observation but complainant refused. On 9.12.04 when she was admitted she was closely monitored and emergency caesarean section was done for the indication of fetal distress. The baby was normal at birth and cried soon after birth. Immediately then pediatrician examined the child and baby was handed over to relatives since no abnormality was noted. It is the usual practice. Later when baby developed distress baby was admitted to the NICU. Baby was intensively cared with ventilation and vigorous treatment for the diagnosed serious condition of pulmonary hypertension. The diagnosed condition is a serious one with high degree of mortality.
Complainant adduced evidence by way of chief affidavit in tune with the pleadings. Ext.A1 is the lawyer notice dt. 8.2.05 sent by complainant to opposite parties. Ext.A2 (a)(b) and (c) are the reply letters send by opposite parties. Complainant alleged in Ext.A1 that the defects diagnosed after the demise of the child ought to have been detected from the ultra sound scanning done on 7.12.4. But complainant could not substantiate this allegation by adducing evidences by her or by examining any expert what she had stated in her affidavit evidence is thus: “7.12.2004-mw XobXn KÀ`-]m-{X-¯n {`qW-¯nsâ Ne-\-¯n\p XS-Êw A\p-`-h-s¸-«-t¸mÄ Rm³ DS³ Xs¶- B-ip-]-{Xn-bn F¯p-I-bp-m-bn. Rm³ ]qÀ® Btcm-K-y-h-Xn-bm-sW-¶pw cp-aq¶p Znh-k-¯n-\p-f-fn km[m-cW kpJ-{]-k-hT \S-¡pw F¶p FXr-I£n Fs¶ Ad-nbn-¨p. 2þmT FXr-I-£n¡v ta Znh-k-§-fn \à Xnc-¡m-bn-cp-¶p. KÀ`n-Wn-I-fmb kv{XoIÄ Ahsc ImWm-\n-cn-¡p-I-bm-sW-¶pT Fs´-¦n-epT Akz-kvXX tXm¶p-I-bm-sW-¦n kvIm³ ]cn-tim-[\ \S-¯-W-sa-¶pT Ft¶m-SpT Fsâ IqsS-bp-f-f-h-tcm-SpT cmw FXr-I£n And-nbn-¨-n-cp¶p. F\-n¡v Ak-z-kvX-X-IÄ A\p-`-h-s¸-«-t¸mÄ 2þmw FXr-I£n kvIm\n§v ]cn-tim-[-\¡v aq¶mT FXr-I£nbpsS ASp-t¯¡v Ab-¡p-I-bpT sNbvXp. cmT FXr-I£n Fs¶ hni-Z-ambn H¶pT ]cn-tim-[n-¡m³ t]mepT {iZ-v[n-¨n-cp-¶nÃ. DS³ Xs¶ H¶mT FXr-I-£n-bpsS tlmkv]n-ä-en sh¨v 3þmT FXr-I-£n- F-\n¡v Obstetric ultra sound scan test \S-¯p-I-bp#nT sNbvXp. Scan report ]cn-tim-[n¨ tijT Hcp-X-c-¯n-ep-ff Ak-zm-`m-hn-I-X-bpT CsÃ-¶mWv 2 Dw 3DT FXr-I-£n-IÄ ]d-ª-Xv.. “As per the above given evidence the main case is that 2nd opposite party did not properly attend the complainant on 7.12.04. At the same time she admits in affidavit evidence that “Scan report ]cn-tim-[n¨v tijT Hcp Xc-¯n-ep-ff Ak-zm-`m-hn-I-X-bpT CsÃ-¶mWv 2DT 3DT FXr-I-£n-IÄ ]d-ªXv’’ Scan report had been examined by 2nd opposite party. 3rd opposite party also attended the matter. If that be so there is no meaning in saying that the defects diagnosed after the demise of the child ought to have been detected from the ultra sound scanning done on 7.12.2004. Complainant approached 2nd opposite party on 7.12.04. It cannot be denied 2nd opposite party suggested obstetric ultra sound scan test and examination of report by her. 2nd opposite arty has given evidence that she had ordered ultra sound study of Biophysical profile to assess fetal well being. There is no evidence to show that the persistent pulmonary hypertension could be detected by antenatal ultrasound. 2nd opposite party specifically contended that the persistent pulmonary hypertension cannot be detected by antenatal ultrasound. Though complainant alleged that the defects diagnosed after the demise of the child could have been detected from the ultra sound scanning done on 7.12.04, no evidence adduced to establish it. No expert evidence or any documentary evidence like authoritative literature to that effect or any sort of study or research has been brought available before the forum to come into such a conclusion that it is possible to detected persistent pulmonary hypertension by antenatal ultra sound. Opposite party also contended that the scan done by the complainant at Bhopal and that done on 7.12.04 had not mentioned anything abnormal about the placenta.
Hence there is burden on the part of complainant to prove that the examination of the test report that had been done on 7.12.04 is sufficient enough to detect persistent pulmonary hypertension. As per the evidence available on record it can be seen the cause of death of baby diagnosed by Echocardiography. Opposite party has also contended that a normal ultrasound study does not rule out all kinds of abnormalities. Opposite party specifically contended that the respiratory distress arising out of persistent pulmonary hypertension can occur at any time after birth. In cross examination DW1 deposed that persistent pulmonary hypertension of the baby cannot be detected before birth. It s not proved otherwise. It is the burden of complainant to prove that it is possible to detect persistent pulmonary hypertension before the birth of the child.
Complainant alleged 2nd opposite party was not even cared to examine the abdomen of the complainant clinically. The affidavit evidence of opposite party is that the complainant presented with the history of perceived decreased foetal movements and she had attached significance to the reported symptom of the patient and examined the patient in detail. Except the evidence adduced by PW1 interested witness by way of affidavit evidence there is nothing to prove the allegation of the complaint. Even an expert is not examined so as to prove this point. It is definite that she went there with some body else. Complainant could have at least examine those persons to prove this or any one else who were present there could have examined. It is a fact admitted by complainant herself that 2nd opposite party had seen her, suggested for ultra sound examination, Report examined and told them that ultra sound examination showed a normal Biophysical profile. Opposite party explained that ultra sound study was ordered to assess the fetal well-being. 2nd opposite party gives evidence by way of affidavit that she has only conveyed the result of ultra sound scan and not given any assurance that there would not be any abnormalities since a normal ultra sound study does not rule out all kinds of abnormalities. Thus the analysis of facts and circumstances reveals that there is no meaning in the allegation that the diagnosis of the baby after the expiry was possible to find out from the ultra sound scanning done on 7.12.2004.
Complainant was admitted in the hospital of 1st opposite party on 9.12.04 following travel. It is an admitted fact that 2nd opposite party examined the complainant and suggested an emergency LSCS. As such the complainant underwent LSCS and delivered a female baby at 12.08 P.M. Complainant pleaded that at 2 P.M the nurses handed over the baby to the complainant’s parents by saying that if any uneasiness is felt upon the baby that is to be reported. Later baby was taken to labour room due to uneasiness and by6 PM condition became worsened and thereby entered into incubator and the very next day at 2 p.m child reported dead. The allegation of the complainant is that the baby was died due to the sheer negligence of opposite parties in providing sufficient treatment. Complainant’s case is that opposite party ought to have confirmed the mass in placenta and placental insufficiency even before forwarding the complainant to C.T scan. If 2nd opposite party had made thorough check up. On 7.12.04 and review dates prior to 7.12.04, she could have easily ascertained the above said condition in placenta even from clinical examination. Another serious allegation raised is that handing over the child after delivery to the relatives and keeping the baby with them without informing the complication which was seen during LSCS had caused the death of the baby.
The condition in placenta could have been easily ascertained if complainant was undergone thorough check up on 7.12.04 and review dates prior to 7.12.2004 is also an important allegation. But complainant by herself or by examining any expert adduced any evidence to substantiate this allegation. It has already been discussed above that complainant could not even produced the bystander with the complaint on 7.12.04 as a witness to examine in box to say what all happened on 7.12.04. Opposite party has adduced evidence by way of affidavit that complainant approached her on 7.12.04 and on examination found uterine fundus corresponded to 38 weeks size, the baby was in longitudinal lie, with cephalic presentation, fetal heart rate 144/mb. She has also sent her for ultrasonography for fetal biophysical profile to assess fetal well being. Ext.B2 (a) dated 7.12.04 Obstetric ultra sound scan report reveals the impression: - “A single live intrauterine gestation with fetus in longitudinal lie with cephalic presentation of sonographic gestational age 37 weeks 5 days + 1-21 days with normal biophysical profile”. It is also recorded fetal stomach, a urinary bladder, kidney as normal. Ext.A1 also admitted that she was subjected to obstetric ultra sound scanning. Ext.A1 does not speak of any complaint regarding the examination/review of 2nd opposite party prior to 7.12.04 though it was specifically written that complainant committed with 2nd opposite party on 6.10.2004, 27.10.04, 19.11.04, 2.12.04 and 7.12.04. If complainant has genuine complaint regarding the check up of 2nd opposite party on the dates above that should have been found place in Ext.A1. There was no whisper about any sort of complaint with respect to check up prior to 7.12.04. It is seen complainant even failed to produce and examine the bystander with her on 7.12.04 while she was approaching 2nd opposite party in order to make out the state of affairs which she/he had experienced with 2nd opposite party. It is true that if any sort of misbehavior or attitude that creates displeasure to patient for consultation or in check up especially incases where emergent attention has been required, it is definitely a wrong that amounts to deficiency in service for which the concerned doctor is answerable. But that who alleges so, has a bounden duty to prove it by cogent and clear evidence. /The complainant herein failed to establish her allegation to this respect by adducing adequate evidence.
It is an admitted fact that the baby was handed over to parents. The allegation of the complainant is that the handing over the child after delivery to the relatives and keeping the baby with them without reporting any complications which was seen by the second opposite party during LSCS has caused the death of baby. Opposite parties adduced evidence by way of affidavit that soon after the delivery the baby was handed over to pediatrician of the hospital and he examined the baby and afterwards baby was given to the relatives.1st opposite party has pleaded that it a routine procedure in the hospital. It is not challenged. 1st opposite party also pleaded that pediatrician is always present inside the operation theatre complex whenever caesarian operations are undertaken. He followed to plead that baby cried immediately and baby was normal in size. 2nd opposite party also stated that the baby was normal at birth. However, complainant has no case that the baby was not normal at the time of birth. Her allegation goes to touch the point that baby should not have been given to relatives since there was complication found during caesarian. She has also no complaint with respect to the treatment given to baby thereafter. PW1 has admitted in cross examination that Baby died after six hours. It shows that at the time of handing over the baby to relatives there was no doubt with respect to the health of the Baby. Complainant neither pleaded in the complaint nor adduced by way of chief affidavit evidence that there was any complication to baby at the time of birth. Baby was delivered at 12.08 P.M. Baby was handed over to relatives after two hours at 2 P.M. Condition of Baby became serious even according to complainant was at 6 P.M. So naturally if the allegation goes to the extent of saying that baby should not have been handed over even on such condition examination of an expert is an unavoidable necessity. Eco cardiography diagnosed the severe persistent pulmonary hypertension which caused the death of child. The expert evidence of DW1/2nd opposite party is that the persistent pulmonary hypertension cannot be detected by antenatal ultrasound. Complainant has the case that the abnormality ought to have been detected from the ultra sound scanning on 7.12.04. That means complainant has the averment that sever persistent pulmonary hypertension can be detected by antenatal ultra sound scanning. 2nd opposite party has taken specific contention that persistent pulmonary hyper tension cannot be detected before birth and also adduced affidavit evidence to this effect. But complainant did not take any initiative to prove her averment by expert evidence. The opinion of expert in this aspect is unavoidable. If complainant is not adducing an expert evidence to prove her averments, the available expert evidence given by DW1 cannot be rejected. In absence of contra evidence and till it is established otherwise it can only be wisely conclude that, persistent pulmonary hypertension cannot be detected before the birth of the baby.
Suppose, placental abnormality found before the delivery, would it changes any differences in the treatment now given is also to be examined for a full swim conclusion as far as this case is concerned. 2nd opposite party has taken the contention that even if the placental abnormality was detected before delivery it would not have made any difference since the indicated treatment would only be delivery by caesarian section which the 2nd opposite party had done. If the remedial measure would only be to take the baby out by caesarian section, it cannot be expected any difference in treatment until and unless it is proved otherwise with support of expert evidence.
In the light of the above discussion taking into consideration the facts, circumstances and available evidence it is found that complainant has miserably failed to establish her case with cogent and convincing evidence. Thus the issues 1 to 3 are found against complainant.
In the result, the complaint is dismissed. There is no order as to costs.
Sd/- Sd/- Sd/-
President Member Member
APPENDIX
Exhibits for the complainant
A1. Copy of the lawyer notice sent to OP
A2. Reply notice sent by OPs
A3.Prescription issued by OP 2
A4. Discharge card dt.13.12.04 issued by OP
A5. Certificate dt.17.12.04 issued by Dr.Ranjith lal
Exhibits for the opposite party:
B1.Sonography report
B2. Original case sheet of complainant maintained by OP
B3. Original case sheet of baby of complainant maintained by OP
Witness examined for the complainant
PW1.Complainant
Witness examined for the opposite party:
DW1. Dr.Jubaireth
/forwarded by order/
Senior Superintendent
Consumer Disputes Redressal Forum, Kannur.
