ORDER PER VINEETA RAI, MEMBER Appellant who was the complainant before the State Commission has filed this First Appeal against the judgment and order dated 30.09.2009 in Complaint No.9/2005 wherein the State Commission dismissed the complaint filed by the Appellant alleging medical negligence against Modern Medical Institute and another, opposite parties before the State Commission and Respondents herein. FACTS In her complaint to the State Commission, Appellant/complainant had alleged that she met with an accident on 13.09.2004 wherein she sustained serious injuries and was admitted to Respondent/Medical Institute for treatment on the same date. However, due to negligence, carelessness and improper treatment by the doctors there and because she was not treated by specialist doctors, her condition deteriorated. It was specifically alleged that her left leg was operated several times and when her condition became serious, she was left to her own fate and discharged. When her guardians demanded ambulance services from the Respondents to take her to Nagpur for proper treatment, this was refused and Appellant relatives had to make ambulance arrangements on their own. Appellant was also not provided relevant documents relating to her treatment despite several requests and was given only an unsigned Discharge Ticket. She was thereafter hospitalized in KRIMS Hospital, Nagpur but because of the wrong and negligent treatment by the Respondent/Hospital, gangrene had set in by then leading to amputation of her leg. Being aggrieved, Appellant issued a legal notice to Respondents to pay Rs.50 lakhs as compensation since her whole future including as a promising prospective engineer had become jeopardized because of her permanent physical handicap as also for mental agony. Respondents instead of paying compensation denied that there was any medical negligence and stated that her condition was properly diagnosed and medical treatment by competent doctors was given to her. Appellant, therefore, filed a complaint before the State Commission on grounds of medical negligence and deficiency in service and requested that Respondents be directed to pay her Rs.50 lakhs with interest @ 12% per annum from the date of admission of the Appellant to the Respondent/Hospital till realization and any other relief as deemed fit and reasonable. Respondents on being served and filed a written statement in which they denied that there was any medical negligence or wrong treatment given to the Appellant as also the specific allegation of the Appellant that she was only attended to by general doctors. Respondents contended that from the time Appellant was brought in the casualty on 13.09.2004 at 4.50 pm, she was attended by the Chief Medical Officer who was on duty and given intravenous fluids, pain killers, tetanus toxide and other necessary drugs after which she was examined by Dr.Lunik Yadu who is a well-qualified specialist orthopedic doctor. An X-ray conducted showed that the Appellant had suffered a fracture of the left femur of the medial tibial condile along with a popliteal artery injury. Appellant parents were informed about the fractures of the left thigh bone, left leg bone and the vascular injury and were told that she would require immediate surgery otherwise there were chances of gangrene setting in. They were specifically informed that even after repair of the vascular injury, chances of thrombosis and gangrene were there and were given the option to shift the Appellant to any other higher medical centre of their choice. Appellant relatives, however, expressed full faith and confidence in the competency of surgeons and staff of the Respondent/Institute after which the Appellant was shifted to the operation theatre and the surgery conducted under general anesthesia by a team of specialist doctors including a surgeon with an MS degree, Dr.Shirish Yadu. Using their best professional judgment, the doctors had two options, i.e. either to tie the injured artery and amputate the leg or repair the artery and establish the blood flow to save the limb. The doctors opted for the second option and also informed and took permission from the relatives of the Appellant for the same. The complicated surgery was carried out successfully and the procedure was fully explained in the medical history sheet which was maintained by the Respondent/Institute and filed in evidence. After the surgery the pulse oxymeter showed 100% oxygen saturation over the left toes and the popliteal vein was checked and found to be full with blood which suggested that blood circulation was established. Appellant was regularly monitored including pertaining to oxygen saturation of the left foot. It was only on 14.09.2004 that Dr.Yadu, the orthopedic surgeon found that pulsations over the left leg and foot were feeble and the oxygen saturation falling. Dr.Yadu immediately informed the Appellant parents about the situation and advised a colour doppler study which was conducted by a specialist radiologist who confirmed that the left lower limb vessel was found sluggish and the condition was diagnosed as blockage due to thrombosis for which a re-exploration operation was advised. Appellant parents agreed to the same and necessary re-exploration surgery was done in the operation theatre. Following the surgery, Appellant condition substantially improved and there was every likelihood of recovery from the injuries. However, the relatives were told that thrombosis can occur in future also and that she might again require surgery. Despite this, suddenly the Appellant relatives took a decision to take away the patient against medical advice and in the absence of the Consultants Doctors on 15.04.2004 at about 6.30 am. Respondents further denied that any request for ambulance had been made and the Respondents came to know only later that the Appellant had been admitted at KRIMS Hospital, Nagpur. It was also denied that at the time of admission of the Appellant in KRIMS Hospital, Nagpur, her condition was poor and that gangrene had set in as alleged by the Appellant and her relatives. It was the Appellant relatives who behaved in an irresponsible manner by taking her against medical advice to Nagpur which was a long journey of 9 hours and at a time when the patient was susceptible to infections to her recently operated site. The State Commission after hearing both parties and on the basis of evidence produced before it, dismissed the complaint. In its detailed order, the State Commission observed that the Appellant contention that the surgery at the Respondent/Institute was done by general doctor was not borne out by the facts since both doctors had M.S. degrees and were specialists in Orthopedics and Surgery with several years of medical experience. Appellant contention that a general surgeon is not competent to conduct vascular surgery was also not accepted by the State Commission on the grounds that the concerned surgeon had performed vascular surgeries on many occasions and evidence of the same was filed before the State Commission. Apart from this, State Commission observed that the Discharge Ticket of the Appellant from the Respondent/Institute containing details of the surgical procedures clearly indicates that due medical care was taken in Appellant treatment and there was no evidence to show that her condition was not satisfactory at the time of discharge. Further, at the time of admission to KRIMS Hospital at Nagpur, there is no specific mention of the onset of gangrene by that Hospital. Apart from this, it is also a fact that the doctors at the Respondent/Institute had warned Appellant relatives of the prognosis that injuries in the popliteal artery can again result in thrombosis and related complications even after the surgery. State Commission observed that in fact this is what happened in KRIMS Hospital when the thrombosis recurred, procedure to remove the same had also to be conducted there. Even thereafter gangrene set in and the leg had to be amputated on 11.10.2004. Following the principles enunciated by the Honle Supreme Court in Jacob Mathew Vs. State of Punjab & Anr. (2005) 6 SCC 1, as to what constitutes medical negligence, the State Commission observed as follows: we find that the doctors of OP No.1 had done their best to save limb of the complainant and successfully operated the Popliteal Artery twice and also removed the thrombosis. As the artery was repaired, but chances of its full repair were feeble and when the complainant was taken to another Hospital at a distance of hundreds of kilometers, against the medical advice, then mainly the risks and results occurred thereafter, were on account of the complainant mistakes. Thus we find that there is no evidence of any negligence on the part of the doctors of OP No.1 and so we decide question Nos.(ii) & (iii) in favour or OP No.1 It is unfortunate that a poor girl of 21 years of age who was a student of Engineering has lost her one leg and is required to live on a single leg for the rest of her life. The amputation of her leg has affected her future and marital aspects adversely, but so far as the OP No.1 is concerned the Hospital and its doctors cannot be held responsible for the same, without any evidence of negligence on their part. Hence, the present First Appeal. Counsel for both parties made oral submissions. Counsel for Appellant reiterated the stand taken before the State Commission that it was because the surgery to repair the popliteal artery was undertaken by a general surgeon instead of by a vascular surgeon that Appellant leg had to be subsequently amputated following infection and gangrene. It was also contended that initially if a diagnostic procedure like the colour doppler had been undertaken, perhaps the second surgery could have been avoided. Counsel for Appellant contended that the State Commission erred in concluding that there was no medical negligence despite clear evidence contained in the discharge certificate from KRIMS Hospital which specifically stated that at the time of admission to that Hospital, Appellant wound had got infected and pus was present and there was evidence of cuticular gangrene as also gangrenous patches over the foot and around the stitches. Counsel for Appellant denied that the Appellant was taken away against medical advice by her relatives and stated that it was the Doctors in the Respondent/Institute who rudely told the Appellant parents that they could take away the patient. Under the circumstances deficiency in service, medical negligence and callousness on the part of the doctors of the Respondent/Institute was fully established. Counsel for Respondent on the other hand stated that the report from the KRIMS Hospital on which Counsel for Appellant has relied was in fact not a case history at the time of admission of the Appellant, nor the discharge certificate at the time of patient discharge on 26.10.2004 but a general certificate which was issued several months later i.e. on 04.03.2005. On the other hand, the discharge summary from KRIMS Hospital dated 27.10.2004 which is a detailed document indicating the diagnosis at the time of admission and the treatment given etc. nowhere states that there was any evidence of gangrene. Specifically the following observations were made in the above summary: ase of RTA on 13.09.2004 at 4.30 pm, Operated for # shaft femur Lt.L.L. with Medial of tibia Lt. with Popliteal injury repair done at Raipur with removal of Thrombus and fasicotomy, Past significant Medical history of vomiting/Seizures, Admitted for ex-exploration. Counsel for Respondent contended that since the patient was discharged in a satisfactory condition, in all probability her wound got infected during the 9 hours journey in an ambulance arranged by her parents, since it is a well-established medical fact that exposure of an affected part in an open atmosphere and in unhygienic conditions can lead to infection and also possible gangrenous development. Counsel for Respondent also pointed out that the onset of gangrene was noted at KRIMS Hospital some days after the Appellant admission to that Hospital and despite exploratory vascular surgery, the problem could not be resolved and the limb had to be amputated about one month after her admission. The above facts indicate that there was no medical negligence or deficiency in the treatment of the patient at Respondent/Institute which was on the same lines as that in KRIMS Hospital against whom Appellant has no complaints. In fact, it was the Appellant relatives who acted in an irresponsible manner and exposed the Appellant to the possibility of infections by taking her away from the Respondent/Institute against medical advice where she was recovering satisfactorily. Apart from the above unfounded allegations, Appellant has not produced any evidence including that of any medical expert to prove that there was any medical negligence in this case. We have carefully considered the submissions made by the learned Counsel for both parties and have gone through the substantial evidence on record. The fact that the Appellant was admitted in the Respondent/Institute where Respondents/doctors conducted the required surgeries including for repair of popliteal artery are not in dispute. Appellant had made several allegations pertaining to her treatment at the Respondent/Institute and it was specifically stated that the problem occurred because she was attended by general doctors who did not have the required specialization and professional competence to conduct the vascular surgeries. We have carefully considered this submission in the light of the evidence on record and we are unable to agree with this contention. It is noted that Dr.Lunik Yadu was a specialist orthopedic surgeon with an MS degree and Dr.Shirish Yadu was an MS in Surgery who had performed vascular surgeries including of the popliteal artery. In the absence of a vascular surgeon in Raipur, it was only appropriate that given the need for an immediate surgery to repair the popliteal artery, a surgeon with adequate practical experience in vascular surgery conducted the same. From the case history and the medical records, it is clear that the vascular surgery was satisfactorily done and the blood circulation had been restored. However, as established by the medical literature produced in evidence, thrombosis can recur even after the vascular surgery which unfortunately happened in this case not only once but even later at KRIMS Hospital where the Appellant was finally taken by her relatives and where despite repair to the popliteal artery on more than one occasion, thrombosis and gangrene set in and the leg had to be amputated. We further note from the medical documents and the case history filed by the Respondent/Institute that due care was taken in the diagnosis and medical treatment of the Appellant as soon as she was brought to the Respondent/Institute. Appellant contention that there was evidence of gangrene at the time of her admission at the KRIMS Hospital is not borne out by the documentary evidence on record since there is no mention in the case history recorded by KRIMS Hospital at the time of her admission and discharge that the Appellant had any symptoms or signs of gangrene. This fact was only mentioned in a general certificate given to the Appellant several months after her discharge and therefore, lacks credibility, particularly in view of the earlier Discharge Certificate where no such observation was made. We further note that Appellant on whom there was onus to do so has not produced any expert evidence including medical evidence to prove that there was medical negligence on the part of the Respondents. The principles of what constitute medical negligence have been clearly laid down in a number of judgment of the Honle Supreme Court including in Martin F. Douza Vs. Mohd. Ishfaq I(2009) CPJ 32(SC) and Jacob Mathew Vs. State of Punjab & Anr. (2005) 6 SCC 1 which have also been cited by the State Commission in its order. While adjudicating allegations of medical negligence on the part of a doctor on the touchstone of the Bolam test, we are required to answer three questions: (i) Whether the doctor in question possessed the medical skills expected of an ordinary skilled practitioner in the field at that point of time; (ii) Whether the doctor adopted the practice (of clinical observation diagnosis including diagnostic tests and treatment) in the case that would be adopted by such a doctor of ordinary skill in accord with (at least) one of the responsible bodies of opinion of professional practitioners in the field and (iii) whether the standards of skills/knowledge expected of the doctor, according to the said body of medical opinion, were of the time when the events leading to the allegation of medical negligence occurred and not of the time when the dispute was being adjudicated. Applying these principles in the instant case, we find that the doctors at the Respondent/Institute who had M.S. degrees in their respective fields and adequate practical experience had, using their best professional judgment, given the correct and appropriate medical treatment which was required to save the limb of the Appellant. There is also evidence to indicate that the surgical procedures were successfully conducted but as is medically well-established in cases of such vascular injuries, the problem of thrombosis can recur as happened in the instant case. There was, therefore, no medical negligence or deficiency in service on the part of the Respondents who had also taken due care to keep the Appellant guardians informed about the surgical procedures and the possible recurrence of the problem. On the other hand we note that it was the Appellant guardians who acted irresponsibly in taking away the Appellant from the Respondent/Institute against medical advice and exposing her to the risk of infections during a long journey of 9 hours. Keeping in view the above facts, we agree with the findings of the State Commission that there is no evidence of medical negligence on the part of Respondents/doctors and the reasons for the unfortunate amputation of Appellant leg cannot be attributed to any deficiency or wrong treatment on the part of the Respondents. We also agree with the findings of the State Commission that in view of the above facts, the Respondent No.2/Insurance Company is also not liable to pay any compensation along with the Respondent/Institute in this case. To sum-up, we uphold the order of the State Commission and dismiss the First Appeal. No costs.