JUSTICE V.K. JAIN, PRESIDING MEMBER (ORAL)

1.      Appellant no. 2 Smt. Pally Rohitha, who is the wife of appellant no. 1, went to Sai Krishna Super Speciality Neuro Hospital, Hyderabad on 27.09.2006 with complaint of difficulty in walking and joint pains for one and a half months.  She was admitted in the said hospital under the treatment of Dr. D. Shridhar, MD, DM (Neuro Physician).  She was subjected to a number of investigations, including MRI of the whole spine and her ailment was diagnosed as Hyperthyroidism + MSD (Multi-symptom disease)/SMA (Spinal Muscular Atrophy).  Her Thyroid profile in the aforesaid hospital showed her T4 to be 29.6 as against the normal range of 60-200 whereas her TSH was found to be 7.4 as against the normal range of 0.25 – 5.  She was discharged with advice to take Physiotherapy and certain medicines including Thyronorm 50 mg were advised to her.  She however, did not report back to the aforesaid hospital and on the advice of one Dr. D.P. Dhairyawan, she came to Krishna Institute of Medical Sciences Ltd. (Respondent No.1).  She remained in the aforesaid hospital from 19.12.2006 to 21.12.2006 under the treatment of Dr. S. Mohandas, Dr. E.A. Vara Lakshmi and Dr. B. Chandrasekhar Reddy.  When she came to the said hospital, she had complaint of pain in lower limbs, associated with weakness of limbs.  On her physical examination, weakness of proximal muscles of all four limbs was found.  She was discharged with advice to take Mecozen Plus tablets, Evion (Vitamin E) capsules and take physiotherapy.  She was advised review after two months in Neurology OPD.  Her ailment was diagnosed as Anterior Horn Cell Disease – Probable SMA-Type III.   Doctor B. Chandrasekhar Reddy also certified that the said disease had no specific treatment.  The appellant no. 1 thereafter, went to Medwin Hospital where she was admitted on 13.02.2007.  It was diagnosed that she had primary Hyperthyroidism due to Parathyroid Adenoma and required surgical excision for the same.  That surgery was later done in Medwin Hospital.  Alleging negligence in her treatment by the doctors of Krishna Institute of Medical Sciences Ltd. (Respondent No.1), she approached the concerned State Commission by way of a consumer complaint.  Her case in nutshell was that her ailment had been wrongly diagnosed without conducting adequate investigations and in fact, the Spinal Muscular Atrophy (SMA) Type-III was not even possible at her age.  According to her, she was wrongly advised that the aforesaid disease was incurable and no medicine for its treatment was available. 

2.      The complaint was resisted by the respondents.  It was inter-alia stated in their written version that the assumption that appellant no. 2 was suffering from Spinal Muscular Atrophy (SMA) was only a suspicion which was not confirmed.  The respondents denied the claim of the complainants/appellants that Spinal Muscular Atrophy (SMA) cannot be developed at her age.  It was also stated in the reply that she having already taken treatment before coming to OP No.1 Hospital, the investigations were not repeated and only E&MG was done in their hospital.  It was also alleged that the findings of the tests which the patient had already undergone were suggestive of Anterior Horn Cell Disease – Probable SMA-Type-III.  It was further submitted in their reply that persons with weakness of limbs and lower motor neuron type without sensory symptoms or signs, without spinal cord involvement are considered to have either muscle or anterior horn cells disease.  It was pointed out that in her case, E&MG findings were suggestive of Neuro Lesion and Muscle Denervation Atrophy without re-innervation. 

3.      The State Commission referred the matter for expert opinion of the Endocrinologist, Neurology Department of Gandhi Hospital, Hyderabad which is a Government Hospital.  The Associate Professor in Department of Neurology, after going through the entire record, opined as under:

“Metabolic Myopathy due to Hyperparathyroid disease is a rare entity.  The Neurological manifestations of Hyperthyrodism are subtle and most often the patients are Asymptomatic.  Generalised muscle weakness and atrophy are the presenting features.  Muscle stiffness without myotonia which occurs in symptomic patients was lacking in this patient.  Severely affected patients may have wadding gait which was not seen in this patient.  Peripheral Neuropathy occurs in 25% of patients.

The EMG study done at KIMS and muscle biopsy done at NIMS indicate a Nerve Disease, which is further supported by Normal CPK done repeatedly.  The scientific data available with the patient when she was in KIMS Hospital, suggests a “Nerve Disease”.  This might have led to a provisional Diagnosis of SMA type III, which was also suspected as a possible cause for her neurological illness, when the patient was in SKS Hospital.  The clinical manifestations of the patient as severe muscle weakness and atrophy and lack of certain vital clinical features like waddling gait and muscle stiffness which are features of Hyperparathyroid Disease might have further stopped the provisional diagnosis of SMA type III.  High Index of suspicion and clinical observation are required to suspect Hyperthyrodism in a neurological patient.  In addition to Hyperparathyroid disease, the patient also has other organ system involvement.  It is difficult to diagnose a case of metabolic myopathy within two days of Hospitalization in view of the reasons mentioned above.

Hence there is no prima facie negligence by the team of Doctors at KIMS while treating Mrs. P. Rohitha on the strength of the documents furnished herewith.”

          Thus, no negligence in the treatment of appellant no. 2 at Krishna Institute of Medical Sciences Ltd. (Respondent No.1) was found by the aforesaid Neurologist. 

4.      The Professor and the Head of Department of Endocrinology in Gandhi Hospital and Medical College was of the following opinion:

“After going through the dossier provided to me and studying the documents, the following opinion is found.

Smt. Pally Rohita 28 yr. W/o. Sri Pally Srikanth is suffering from Hyperparathyroidism, primary due to parathyroid adenoma, sub clinical (mild) Hypothyroidism with Vit.D deficiency.

During Hyperparathyroidism is a rare condition occurs 0.1 to 0.3 per 1000 patients.  The commonest presentation is asymptomia and most of the cases are diagnosed incidentally.  The common symptoms are bone pains and fatigue and neuropsychative complaints.  The patient presented with muscle weakness (Myopathy) which is rare type of presentation.  There was no. C/o. Osteopenia (ostropania on initial x rays whereas there are florid changes on the subsequently taken x ray (according to the reports provided.”

If the case was followed probably, the condition would have diagnosed in the subsequent sections.”

Dr. L.N.N. Murthy of Gandhi Hospital, after examining several X-Rays and CT Scans of the patient dated 20.02.2007 and 26.02.2007, reported as under:

Findings:

A small enhancing mass is seen posterior to right lobe of thyroid gland is highly suggestive of Parathyroid Adenoma.

          Based upon the report of the above referred doctor and considering that no medical expert had been examined by the complainants/apellants, the State Commission dismissed the complaint.  Being aggrieved, the complainants/appellants are before this Commission by way of this appeal. 

5.      It is settled legal preposition that the onus of proving the alleged negligence in the treatment of a patient lies with the person alleging medical negligence.  Therefore, the onus was upon the complainants/appellants to prove that the doctors in Krishna Institute of Medical Sciences Ltd. (Respondent No.1) were negligent in her diagnosis and treatment at the said hospital.  Admittedly, no doctor was examined by the complainants/appellants to examine the record pertaining to her treatment in Krishna Institute of Medical Sciences Ltd. and give opinion as to whether there was any negligence in diagnosis of her ailment and in her treatment in the said hospital.  The surgery of complainant no. 2 was admittedly performed at Medwin Hospital.  No doctor from Medwin Hospital was examined to prove the alleged negligence in the treatment of complainant no. 2 at Krishna Institute of Medical Sciences Ltd.  Respondents no 2 to 4 who themselves are doctors, have denied alleged negligence in the treatment of complainant no. 2.  More importantly, the Neurologists of Gandhi Hospital, which is a well-known Government  hospital of Secunderabad, and who is in the rank of an Associate Professor, has categorically opined that prima facie there was no negligence in the treatment of complainant no. 2 in Krishna Institute of Medical Sciences Ltd.  The Professor and Head of Department of Endocrinology also examined the documents relating to her treatment and he also did not claim any negligence in her treatment.  Rather, he was of the opinion that the rare condition exhibited by complainant no. 2 occurs only in 0.1 to 0.3 per 1000 patients.  According to him, the commonest presentation of such disease is asymptomia and most of the cases are diagnosed incidentally.  According to him, only rarely the patients presented with the muscle weakness.  According to him, had the case been followed properly, the condition would have diagnosed in the subsequent sections.  Admittedly, complainant no. 2 did not report back in Krishna Institute of Medical Sciences Ltd. after she was discharged on 21.12.2006.  It is quite probable that had she continued visiting, the said hospital as was advised at the time of discharge, her ailment would have been diagnosed in due course.  As far as the opinion of the Radiologist of Gandhi Hospital is concerned, his opinion was given after CT Scans were conducted on 20.02.2007 and 26.02.2007.  Therefore, his report does not show any negligence on the part of the respondents in treatment of complainant no.2.

6.      The main contention of the complainants/appellants is that her problem was diagnosed as Anterior Horncell disesase probable SMA without conducting requisite investigations.  On a perusal of the record, I find that even Sai Krishna Super Speciality Neuro Hospital in its report diagnosed her ailment as Hyperthyroidism + MSD (Multi-symptom disease)/SMA (Spinal Muscular Atrophy).  The said opinion was based upon several investigations conducted in Sai Krishna Super Speciality Neuro Hospital which included MRI of the whole spine and ultra sound scan of the abdomen besides several blood tests.  The respondents had no reason to suspect the report of Sai Krishna Super Speciality Neuro Hospital and therefore, they cannot be said to be negligent in the treatment of complainant no. 2 only on account of having not repeated the investigations which she had already undergone at Sai Krishna Super Speciality Neuro Hospital.  The diagnosis by Sai Krishna Super Speciality Neuro Hospital being on the lines of the diagnosis at Krishna Institute of Medical Sciences Ltd., it would be difficult to say that no qualified doctor, on the basis of the investigation reports available to him and the clinical examination of the patient, could have diagnosed it as a case of Anterior Horn Cell Disease – Probable SMA-Type III. 

7.      The learned counsel for the appellants/complainants refers to the decision of this Commission in Yashodha Super Speciality Hospital & Anr. Vs. K.U.M.R. Prasad & Anr., FA No. 194 of 2006, decided on 26.09.2011 where this Commission, despite the complainant having not adduced any expert evidence, held the doctors to be negligent in the treatment of the complainant, noticing that expert evidence is not obligatory.  Reliance in this regard was placed in the decision of the Hon’ble Supreme Court in V. Kishan Rao Vs. Nikhil Super Specialty Hospital (2010) 5 SCC 513.  There is no quarrel with the legal preposition that a case of medical negligence can be made out even without producing the evidence of an expert.  But, where in a particular case, the alleged negligence stands proved or not, would depend upon the facts of each case.  The onus will always be upon the complainant to prove, whether by producing expert opinion or otherwise, that there was negligence at the hands of the doctor in the treatment of the patient.  In the present case, no such negligence on the part of the doctors could be established by the complainants/appellants.  On the other hand, the opinion given by the Neurologist of Gandhi Hospital, Secunderabad indicates that there was no negligence in her treatment at Krishna Institute of Medical Sciences Ltd.

8.      The learned counsel for the appellant also refers to the decision of the Hon’ble Supreme Court in Malay Kumar Ganguly Vs. Sukumar Mukherjee (2009) 9 SCC 221 where the Hon’ble Supreme Court referred to its earlier decision in Martin F. D’Souza Vs. Mohd. Ishfaq (2009) 3 SCC 1 wherein it was held that a doctor should not merely go by the version of the patient regarding his symptoms, but should also make his own analysis including tests and investigations where necessary.  There is no quarrel with the aforesaid legal preposition but in the present case, the requisite investigations had already been done before complainant no. 2 came to Krishna Institute of Medical Sciences Ltd. And the doctor had no reason to suspect the evidence of the investigations conducted at the previous hospital.  They felt necessity of one additional test namely E&MG which they got duly conducted at the said hospital.  Therefore, it cannot be said that the doctors at Krishna Institute of Medical Sciences Ltd. had not got necessary investigations done before diagnosing the ailment of the complainant.  In fact, they could not finally diagnose her ailment since the symptoms which they found during her clinical examination and the report of the investigations available to them, did not suggest that she was suffering from Hyperthyroidism + MSD (Multi-symptom disease)/SMA (Spinal Muscular Atrophy).  Had complainant no. 2 continued treatment in Krishna Institute of Medical Sciences Ltd., in all probabilities, she would have been subjected to further investigations and the correct diagnosis would have been possible. 

9.      For the reasons stated hereinabove, I find no good reason to interfere with the view taken by the State Commission.  The appeal is accordingly dismissed with no order as to costs.