C.D.NO.40 OF 2003

Between:

1.      Dr.K.Srikar Reddy S/o Krishna Reddy
Aged 30 years, Occ: Indian Foreign Services

2.  P.Rama Krishna Reddy S/o late Seetharam Reddy
     Aged 53 years, Occ: Advocate

3.  P.Swapna Sundari W/o P.Rama Krishna Reddy
    Aged 50 years, Occ: Household        
    All are R/o H.No.3-5-1092/7, Sri Venkateshwara Colony
    Narayanaguda, Hyderabad                                                                                                                                                              Complainants

     A N D

1.      Srishti Associates, a proprietory concern
 Having its office at 3-4-140, Barkatpura
Hyderabad rep. by its Proprietor
Dr.M.Padmanabh Reddy, aged 45 years,
C/o Shalini Maternity Hospital
3-4-140, Barkatpura, Hyderabad-500 027

2.  Shalini Maternity Hospital
     3-4-140, Barkatpura, Hyderabad
     rep. by Dr.M.Padmanabh Reddy
     Proprietor of Srishti Associates

3.  Dr.P.Malathi
     aged about 40 yrs, Occ: Govt. Service
     Government Maternity Hospital
     Nayapool, Hyderabad,  Consultant
     Obstetrician and Gynaecologist
     Shalini Maternity Hospital
     3-4-140, Barkatpura, Hyderabad-027

4.  Dr.B.Thejeswari (since died)
     aged 35 years, occ: Doctor
     Resident Obstetrician and Gynaelogist
     Shalini Maternityh Hospital,
    3-4-140, Barkatpura, Hyderabad -027

5.  Dr.L.Sudhakar
     aged 30 yrs, Occ: Doctor (Anesthesiologist)
     Shalini Maternity Hopsital
     3-4-140, Barkatpura, Hyderabad-027

6.  Dr.Shyam Sundar
     Aged 45 years, Occ: Doctor
    (Consultant Anesthesiologist),
    Shalini Maternity Hospital
    3-4-140, Barkatpura, Hyderabad-027

7.  M/s New India Assurance Co., Ltd.
    Branch Office 6-11-203, H.No.10-214
    P.H.Road, Opposite District Court,
    Chittoor-517001, A.P.
    (Impleaded as per the orders in
     I.A.No.1636/2005 dt.17.6.2008)

                                                                                  Opposite parties

Counsel for the Complainants                    Mr.D.Devender Rao
Counsel for the opposite parties No.1&2    Mr.Rupendra Mahendra
Counsel for the opposite party no.3           Mr.D.Seshadri Naidu & Hari Babu
Counsel for the opposite party no.4           O.P.No.4 died
Counsel for the opposite party no.5           Mr.D.Krishna Murthy
Counsel for the opposite party no.6           Mr.R.Raghunandan Rao

QUORUM:    THE HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT

SMT M.SHREESHA, LADY MEMBER
                                      &
          SRI G.BHOOPATHI REDDY, MEMBER

FRIDAY, THE TWENTY NINETH DAY OF AUGUST
TWO THOUSAND EIGHT

   Oral Order ( As per the Smt M.Shreesha, Member)
***

The brief facts as set out in the complaint are that the first opposite party  no.1 is a proprietary concern and Dr.M.Padmanabh Reddy is the sole proprietor of first opposite party and second opposite party hospital is owned, managed and administered by first opposite party.  The third opposite party is an Assistant Professor working in Government Maternity Hospital, Nayapool and also attends second opposite party hospital as consultant obstetrician and gynecologist.  The fourth opposite party is working as resident obstetrician and gynecologist in second opposite party hospital.  Both fifth and sixth opposite parties are the consultant anesthesiologists of second opposite party hospital.  The first complainant is the husband of the deceased.  The second and third complainants are her parents and she is the only daughter and passed B.E., in first division and did M.S (Computer Science) from Cleveland State University, Ohio State, USA., from May 2000 to December 2001.  During her studies at USA she secured Graduate Assistantship and she was earning around $ 10,000 per annum.  She was genius and meritorious student through out her education career.  The complainants submit that the first complainant married the deceased Srilatha on 1.8.2001.  The first complainant passed M.B.B.S., from Kakatiya Medical College, Warangal and by the date of the marriage he got selected in Indian Foreign Service (IFS).  The second complainant is a practicing advocate at Hyderabad.  The deceased was working with Gateway Software Solutions as project consultant and earning Rs.25,000/- per month.  The deceased was planning to accompany the first complainant wherever he was posted in service in India or abroad and also to take-up employment in such places.  She was expecting to earn till the age of sixty-five years.  The first complainant will be posted for (10) years in developed countries, (10) years in developing countries and (10) years in India.  The deceased would have earned US$ 60,000 per annu8m in developed countries, $US 20,000 per annum in developing countries and in India for 20 years she would have earned on an average a sum of Rs.40,000/- per month.  Thus, she could have earned a minimum of Rs.4.72 crores during her lifetime. 

The complainants submit that for delivery, the deceased was admitted to Jaya Nursing Home at Narayanaguda, Hyderabad on 5.3.2003 at about 10.00 A.M.  The first complainant came from New Delhi around 8:30 P.M> and found that said nursing home did not have ultrasound facility to check fetal well being and he consulted Dr.V.S.Rajesh Khanna, who took him to third opposite party at Woodlands Hospital, Barkatpura Hyderabad around 10.15 P.M. for advice.  The third opposite party directed for shifting the deceased immediately to the second opposite party hospital where ultrasound facility is available.  She instructed over telephone to the fourth opposite party to admit the deceased in second opposite party hospital.  Acting on the said instruction of third opposite party, the deceased was admitted to the second opposite party hospital at about 11.30 P.M. on 5.3.2003.  The fourth opposite party who is a resident Obstetrician and Gynecologist, examined the deceased and opined that ultrasound examination is not necessary as there was sufficient amniotic fluid (amniotic fluid is fluid surrounding the fetus in the womb), normal fetal heart rate and the deceased was in active labour with 3 – 4 cms. Cervical dilation (cervix is the lower segment of the uterus) and also that the normal vaginal delivery of the baby would occur within three hours.  The fourth opposite  party also said that they would administer epidural analgesia, for the relief of labour pains since the deceased complained of pain during vaginal examination.  Dr.V.S.Rajesh Khanna brought the third opposite party to the hospital at 11:45 P.M.  The third opposite party examined the deceased and concurred with the course of treatment suggested by the fourth opposite party.  All through, the deceased was stable and in fact walked into the labour room without anybody’s support.  At that stage, Dr. V.S.Rajesh Khanna left for home and first complainant was with the deceased in the labour room as attendant.  The second and third complainants were also in the hospital at the relevant time.  Then at around 00:05 A.M., the deceased was given enema.  The third and fourth opposite parties induced labour with Syntocinon drip and Artificial Rupture of Membranes (ARM).  The fifth opposite party inserted epidural catheter and injected Lignocaine, Fentanyl and also injected Bupivacaine at frequent intervals.  At the same time the fourth opposite party gave drugs like Drotin, Epidosin and Buscopan intravenously at frequent intervals for cervix dilatation and acceleration of labour.  The deceased was made to lie in supine position through out.  At about 2:45 A.M, the third and fourth opposite parties asked the deceased to bear down the baby by voluntary efforts.  While so, at about 3.00 A.M. fetal distress was noticed with fetal heart rate frequently going down to 80 beats per minute (BPM) from the normal 140 BPM.  Then Syntocinon drip was stopped.  Sensing alarming situation, the first complainant, to avoid any risk to the mother and baby requested the third, fourth and fifth opposite parties to shift the deceased to operation theatre and perform immediate cesarean section.  But, the third, fourth and fifth opposite parties declined to act on the said request saying that nothing was serious and normal delivery would occur. 

The complainants further submit that at about 3:15 A.M. though the fetal heart rate was 110 BPM, which was far less than normal, 140 BPM Syntocinon drip was started again and the deceased, was again asked to bear down the baby by voluntary efforts.  The fifth opposite party repeated injection Bupivacaine into epidural catheter at 3.20 A.M. stating that delivery would take place in the next thirty minutes and this would mitigate pain that would be severe.  Though the deceased was in severe distress, she was forced to bear down the baby.  The deceased tried hard few times and pleaded with the third and fourth opposite parties to do operation to take out the baby.  But the third and fourth opposite parties still insisted the deceased to bear down the baby by voluntary efforts.  At about 3.30 A.M., the first complainant, to his dismay, noticed the deceased going into shock with cyanosis on her lips and face and losing consciousness.  (Cyanosis is bluish discoloration of skin and mucous membranes like lips due to severe deficiency of oxygen with the oxygen saturation in blood falling extremely low). The first complainant insisted for checking the blood pressure, which was then 80/50.  Since the condition of the deceased being deteriorated rapidly, the first complainant requested the third, fourth and fifth opposite parties to give immediate treatment.  But to the complainants dismay he found no resuscitation equipment in the labour room.  First complainant pleaded with the third, fourth and fifth opposite parties to rush the deceased to the theatre and do the best possible to save the deceased and the baby.  But opposite parties were not responding to the situation properly.  Then the firth complainant over phone asked Dr.V.S.Rajesh Khanna at 3:30 A.M. to come to the hospital immediately, as the condition of the deceased was worsening.  The first complainant screamed at the opposite parties for shifting the deceased into operation theatre immediately.  The deceased was shifted to operation theatre only at 3:40 A.M.   By then vital time for resuscitation of the deceased and the fetus was lost. 

Dr.V.S.Rajesh Khanna came down to hospital around 4:10 A.M.  The third opposite party requested Dr.V.S.Rajesh Khanna to assist the attending doctors in resuscitation of the deceased.  First complainant accompanied Dr.V.S.Rajesh Khanna into operation theatre, where they found the situation shocking, as the deceased was lying unconscious in supine position on the trolley with total cyanosis of the body.  The deceased was not even shifted onto the operation table and she was being given oxygen with nasal prongs, which barely supplies 30% of the required amount of oxygen instead of supply of 100% oxygen with endotracheal intubation.   By then the deceased suffered convulsions, which means irreversible brain damage has occurred.  Only when the first complainant screamed at the attending doctors, the deceased was intubated.  By then cardiac arrest had taken place as the heart was also starved of oxygen.  The fifth opposite party and Dr.V.S.Rajesh Khanna have started cardiopulmonary resuscitation.  Then around 4:20 A.M., the third and fourth opposite parties were requested by first complainant to do delivery by cesarean section or by using forceps or by venutose extraction, which they were expected to do so, to save the lives of the mother and baby.  The request of the first complainant just fell on their deaf ears and this resulted in loosing the last opportunity to save the deceased and the baby.  The complainants submit that around 4:30 A.M. sixth opposite party, who is consulting senior anesthesiologist of the second opposite party hospital, came and examined the deceased.  At 4:30 A.M. the deceased was having persistent cyanosis and heart rhythm was idiosyncratic with wide QRS complex (QRS is the waveform of heart contractions recorded on electrocardiogram (ECG)].  Wide QRS complex rhythm means it is abnormal heart rhythm, which has to be brought ot normal by giving DC shock with defibrillator and/or drugs like sotalol, lignocaine, bretylium etc.  They did not perform DC shock and did not give drugs to normalize heart rhythm.

The deceased was declared dead at 5:30 A.M. on 6.3.2003.  The cause of death of the deceased was not mentioned in the death certificate or in death summary of the deceased.  The cause of death of the deceased was written in the case sheet late as “cardio pulmonary arrest due to amniotic fluid embolism.”  When every one was in shock on hearing the news of the sudden demise of the deceased, the opposite parties tampered with the case sheet.  They did not take steps to perform autopsy of the deceased, which is a must in all cases of sudden death, especially in cases where anaesthesia is administered.  The autopsy was not done with a criminal intention to suppress the real cause of death.  It is submitted that the death of the deceased and the baby occurred due to the gross negligence in handling the delivery of the deceased by the opposite parties.  In the  death summary, it was wrongly mentioned that labour analgesia was given on demand.  In fact Labour Analgesia was given on the insistence of the third and fourth opposite parties, and the consent of the first complainant was mechanically obtained.  Similarly, the cause of death in the case sheet was wrongly mentioned as amniotic fluid embolism.  The following commission and omissions on the part of the opposite parties would prove that the death of mother and baby occurred due to sheer negligence and deficiency in service on part of the opposite parties.

The complainants further submitted in their complaint that the following method of treatment given by opposite parties to the death of the patient:

(i)                  The deceased was administered the local anaesthetic drug Bupivacaine for epidural analgesia at frequent intervals than normally required, which have caused complications like hypotension, cyanosis etc. 

(ii)               For making cervix to dilate and accelerate labour they have used three drugs Drotin, Epidosin and Buscopan intravenously while the normal practice is to use only one drug.  They gave all these drugs at frequent interveals intravenously, which led to drug toxicity and resulted in complications like hypotension, cyanosis etc.

(iii)             There was no proper monitoring by third, fourth and fifth opposite parties after epidural analgesia was given and also the mandatory equipment like pulseoxymeter and cardiac monitor were not used, so early signs of complications were not detected.  There were no resuscitation equipment and drugs available in the labour room, which is mandatory if epidural analgesia is administered.  Hence resuscitation could not be performed in labour room even though complications were developed in labour room itself. 

(iv)              Necessary precautions like positioning the patient in left lateral position to prevent hypotension are not take; instead the deceased was put in supine position which is contraindicated during labour.

(v)                Even after complications started manifesting to thenormal observation level in the labour room from 3:00 A.M. when Syntocinon drip was stopped due to fetal distress and where resuscitation equipment was not available there was (40) minutes delay in shifting the deceased to the theatre.  Even the case sheet shows that fifth opposite party, anaesthesiologist did not monitor the patient from 2:30 A.M. till 4:00 A.M.  Case sheet shows that deceased was not even attended by the third and fourth opposite parties from 3:40 A.M. to 4:15 A.M. even after shifting her to operation theatre when she had already developed complications.  No steps were taken to do emergency cesarean operation for which the deceased was shifted to operation theatre and the deceased was left on trolley in unconscious state and not even shifted to operation table.

(vi)              As endotracheal intubation to give 100% oxygen was not done immediately even after noticing the patient in unconscious and in cyanosed condition, cyanosis persisted and progressed to Persistent Progressive Cyanosis.  Even after noticing Persistent Progressive Cyanosis as 100% oxygen was not supplied immediately it lead to irreversible brain damage manifested by convulsions and progression to cardiac arrest.

(vii)           Emergency delivery by way of forceps/vacuum extraction in the labour room and delivery by forceps/vacuum extraction/immediately cesarean section/perimortem cesarean section would have helped in mother’s resuscitation and save both the lives.  But it was not done. 

(viii)         Didn’t perform DC shock or administer drugs to normalize Heart rate even after noticing wide QRS complex to revive the deceased.

(ix)             Hospital did not have facilities to give advanced cardiac life support, which is a must if labour analgesia is administered. 

They contend that the causes of the complications are as under:

I.                    High block/Total spinal block resulting from epidural analgesia.  High block/Total spinal blockade is the complication of epidural analgesia due to the puncture of dura (outer most layer covering spinal cord) with inadvertent subarachnoid (middle layer membrane covering spinal cord), epidural injunction as drug comes in direct contact with spinal cord and cerebrospinal fluid which makes the drug to reach upper spinal cord and brain.  This leads to hypotension, apnea ( no breath), unconsciousness and bradycardia.

II.                  Drug toxicity:  Three drugs were given for same effect of dilatation of cervix and acceleration of labour, which is against any norms of medical practice.  Usually one drug should be used.  Drotin contains drug Drotaverine 1 ampule of which should be given intramuscularly and repeated after 2 hours if necessary.  But in the given instance it was given intravenously and at 1 hourly interval.  Rapid intravenous injections have led to fall of blood pressure and the deceased going into shock and cardiovascular collapse.  Epidosin contains drug Valethamate 1 ampule of which should be given intramuscularly and repeated after 2 hours if necessary.  But in the given instance it was given intravenously and at 1 hourly interval.  Rapid intravenous injections have led to fall of blood pressure and the deceased going into shock and cardiovascular collapse.  Epidosin contains drug Valethamate 1 ampule of which should be given intramuscularly and repeated after 30 minutes only once if necessary.  But in the given case the deceased was administered 1 ampule every 30 minutes.  Buscopan contains drug Hyoscine Butyl Bromide, 1 ampule should be given at 1 hourly intervals.  But in the given case the deceased was administered 1 ampule every 30 minutes.  Thuse deceased ahd developed severe hypotension and went into shock because of unregulated and unwarranted toxic doses of drugs for cervix dilatation on deceased who is on epidural analgesia.

III.                Vaso Vagal shock:  As the patient was put in supine position ( which is contraindicated during labour and especially when epidural analgesia is administered) she had developed severe hypotension ( due to sympathetic blockade by epidural analgesia, excessive and inadvertent dosage leading to toxicity of the drugs along with lack of monitoring by third, fourth and fifth opposite parties. ) and when the deceased was asked to bear down by voluntary efforts by valsalva maneuver, the deceased had suffered Vasovagal attack, which progressed to cardiac arrest as she was not treated promptly.

Had the opposite parties not administered the drugs indiscriminately, had they taken due care and caution to detect and arrest the complications likely to occur due to the said drugs and had the opposite parties done the resuscitation measures promptly when complications occurred, life of the mother and baby would have been saved.   Even if one assumes the deceased suffered amniotic fluid embolism (AFE) as stated in the case sheet, which is presented with hypotension, hypoxia, pulmonary edema, tachycardia, convulsions and consumptive coagulopathy with hemorrhage.  In the present case  there was bradycardia instead of tachycardia and there was no pulmonary edema and hemorrhage.  Convulsions must be an initial manifestation in AFE due to profound degree of hypoxia, but in this case convulsions occurred in final stage as brain damage occurred due to non-supply of adequate oxygen even after cyanosis was noticed.  The management for AFE is ought to be as mentioned below:

a)     Supply of 100% oxygen immediately by endotracheal intubation.  The first objective is to secure the patient’s airway and provide effective ventilation and oxygenation by endotracheal intubation and mechanical ventilation with volume-cycled respirator.

b)     Immediate delivery of the baby by cesarean section, forceps or venutose extraction before cardiac arrest and perimortem cesarean section after mother suffers cardiac arrest.  Lateral tilting should therefore be the first maneuver in the event of cardiac arrest, but if sufficient cardiac output is not achieved within five minutes, delivery of the fetus should be performed.  Emptying of the uterus will increase cardiac output by 60-80% of pre-pregnancy levels and thus recovery of maternal circulation occurs and survival of both mother and fetus is ensured.

But in the instant case, the opposite parties did not do the above resuscitation measures.

The complainants submit that the sudden and unexpected demise of the mother and baby in the wee hours on 6.3.2003 shocked the complainants.  The first complainant lost the companionship of a lovable wife within two years of marriage, more particularly when he was expected to become a father of a child, is unable to come out of the shock and mental agony.  The pain on account of deprivation of the said companionship would be everlasting.  He is disturbed and unable to concentrate on his service.  The second and third complainants brought up their daughter with love and affection and educated her in India and abroad spending a lot of money.  Her sudden demise left indelible shock I their mind.  The second complainant is unable to come out of shock and depression and unable to carry out his professional work.  The only daughter’s sudden death affected the third complainant to such an extent that she  became unconscious, as soon as she learnt about the news of the said death.  She is still depressed and under the spell of the shock and mental agony.  She is ruminating her daughter’s act from her childhood lying on the bed.  She is in a state of severe depression and any amount of consolation is proved futile.  The loss of the mother and the baby is being felt in perpetuity and immeasurable by the complainants and of their family members.  The loss of the deceased in the family is felt not only in terms of pain and agony but also in terms of deprivation of the income of the deceased.  The deceased, with her bright and meritorious educational career, would have earned for herself and for the family, during her lifetime an amount of not less than Rs.4.72 crores.  The deceased was employed abroad and here and contributing her earnings to the complainants.  The second and third complainants were expecting to be maintained and cared by their daughter in their old age.  Had the deceased been alive, the old age of the second and third complainants would have been easy and comfortable.  In view of the above, the complainants estimate the damages suffered by them Rs.4,25,65,000/-.

The details of the said damages are given below:

However, the complainants have restricted the claim to Rs.1,00,00,000/- (rupees one crore).

It is therefore prayed that first to sixth opposite parties be directed to pay to the complainants a sum of Rs. 1,00,00,000/- ( Rupees one crore) jointly and severally, together with interest @ 24% per annum from the date of complainant till the date of realization and other costs and reliefs.

The first and second opposite parties filed counter denying that the death of Smt Srilatha Reddy (hereinafter referred to as the Deceased) occurred due to gross negligence and deficiency in service on the part of the opposite parties and the complainants are put to strict proof of the same.  Dr.M.Padmanabh Reddy, Sole Proprietor of first opposite party established Shalini Maternity Hospital with the intention of serving the neighbourhood community in the year 2001, and he is also the Neonatologist of the hospital.  They submit that the deceased was treated free of charge as the husband of the deceased i.e., first complainant happened to know the fifth opposite party intimately as both studied in the same institution during their MBBS course and also in view of the fact that Dr.Rajesh Khanna who is a close friend of the fifth opposite party had requested for admission of the deceased in the hospital and requested for treatment at free of charge.  Therefore the service was rendered free of charge.  The complainants cannot be termed as consumers under the provisions of the Act, as such the complaint is liable to be dismissed.   Second opposite party hospital offers the highest quality of exclusive, modern facilities with more than 100% back up to facilitate provision of excellent maternity care in a supportive, comfortable and relaxed environment.  It is a well planned hospital complex that has been designed to facilitate the process of giving maternity care in a quick, effective, safe and pleasant manner.  It consists of 2 well equipped Operation Theatres, 2 Labour beds, 6 Recovery beds and 6 Bed neonatal care unit.  This hospital is equipped by advanced life supporting and critical care equipment like Boyle’s apparatus (2), Pulseoxymeter, non invasive B.P.Monitor, cardiac Monitor, Cardiac defibrillator, CTG Monitor, Ultrasound Machine, high capacity generators (2) and well qualified nursing staff and experienced resident doctors.  It is true that Dr.P.Malathi ( third opposite party) is a visiting consultant Obstetrician and Gynecologist at Shalini Maternity Hospital.  She is often utilizing the facilities of Shalini Maternity Hospital from past two years and she is acquainted with the facility and protocols of Shalini Maternity Hospital.  It is true that fourth opposite party is working for Shalini Maternity Hospital as resident doctor on a monthly salary basis.  It is true that fifth and sixth opposite parties are consultant Anesthesiologists, whose services are regularly utilized as a group for the patients of Shalini Maternity Hospital.  However services of the above mentioned Anesthesiologists are also facilitated by Shalini Maternity Hospital for the patients of visiting consultants at the request of such visiting consultants.  AS per the request of third opposite party and Dr.Rajesh Khanna, fifth opposite party was called for the purpose of Labor Analgesia.  The first and second opposite parties submit that to the knowledge of the opposite parties herein, the deceased was staying at Delhi with first complainant and was visiting Hyderabad only once in a while and she was permanently residing at Delhi, as such the contention that she was working with Gateway Software Solutions at Hyderabad and earning Rs.25,000/- per month cannot be accepted as true and a such denied by the opposite parties herein.   The further contention of the complainants that the deceased was planning to work wherever the first complainant no.1 was to be posted in India or abroad and would have earned $60,000 per annum in developed countries and $20,000 per annum in Developing countries and an average of Rs.40,000/- per month in India is totally incorrect and cannot be accepted as true.  Further the same is not supported by any material to substantiate the said figures.  Therefore the contention of the complainants that she would have earned a minimum of Rs.4.72 crores during her life time is totally denied and the complainant is put to strict proof of the same. 

It is submitted by first and second opposite parties that on the instructions received from the third opposite party, fourth opposite party admitted the deceased at 11-45 p.m. on 5.3.2003 but not 11.30 p.m., as stated in the affidavit.  It is true that the patient was in active labour with 3 to 4 centimetres of Cervical Dilatation with intact membranes.  However, these findings were entered on the case sheet and the contention of the complainant that the same were discussed with the first complainant is not correct.  The other contention of the complainant that fourth opposite party opined that Ultrasound Examination was not necessary as there was sufficient Amniotic Fluid and further that normal Vaginal delivery would occur within 3 hours.  It is further submitted that the fourth opposite party herein examined the patient and explained to the first complainant that she would discuss the clinical status with the consultant.  Meanwhile fourth opposite party explained about the availability of labour Analgesia facilities at the Hospital.  At that juncture Dr.Rajesh Khanna who is also an Anesthesiologist and a friend of first complainant also was informed about the availability of Labor Analgesia services and after deliberations between Dr.Rajesh Khanna and Dr.Srikar Reddy i.e., the first complainant and the deceased, Dr.Rajesh Khanna convinced them that it is a safe procedure and informed that the Epidural will be administered by one of his colleagues in the Hospital.  Thereafter fourth opposite party called the third opposite party and informed her about the clinical status.  Both the deceased and the first complainant discussed amongst themselves about the option and agreed for Epidural Analgesia and they had gone through the Consent Form and signed the same.  It is further submitted that all the details of the Epidural Analgesia was explained to the deceased and Dr.K.Srikar Reddy (first complainant) .  They discussed about the option and agreed for the Epidural Analgesia and have gone through the consent form and signed the same.  It is submitted that the averments therein that Dr.Rajesh Khanna left Hospital at 11.45 p.m. at the time when the deceased was being escorted to the Labor Room is not correct.  Third opposite party examined the deceased, but it is not correct to say that she concurred with the line of treatment suggested by fourth opposite party.  In fact as per the protocol, the question of fourth opposite party being a Resident Doctor would not suggest in treatment, but would follow the instructions and the line of treatment suggested by the Consulted.  Accordingly the fourth opposite party was following the instructions of third opposite party who was the consultant concerned to the case.  It is true that first complainant was with the deceased in the Labor Room as attendant.

The first and second opposite parties submit that it is pertinent that the deceased was given enema and administered Epidural Analgesia as explained above. Further various drugs were administered in accordance with the Consultants instructions for Cervical Dilatation and acceleration of labor.  The administrations of drugs etc. are recorded in the case sheet.  It is not correct that the deceased was made to lie in supine position throughout and further it is denied that at 2.45 A.M., the fourth opposite party herein along with third opposite party had asked the deceased to bear down the baby by voluntary efforts.  In fact the deceased was made to lie down on lateral position and was conversing with the husband all the time contrary to what is stated by the firs complainant that the deceased was made toile in supine position.  Further fourth opposite party nor third opposite party had asked the deceased to bear down the baby by voluntary efforts.  It is submitted that the labor was progressing well and uneventfully the deceased was being monitored through Pulseoxymeter, cardiac monitor and non invasive BP monitor that was connected to the deceased and also manually at regular intervals by Dr.Sudhakar, Dr.P.Malathi and fourth opposite party.  At about 3.00 A.M. in accordance with Dr.P.Malathi’s instructions nurse has stopped syntocinon drip.  The condition of the fetus was being monitored at regular intervals by CTG and fetal heart sound was normal till 3.40 a.m.  All vital statistics of the deceased were normal till 3.40 A.M.  It is not true that fetal distress was noticed on electronic fetal monitor at 3.00 A.M. and it is not true that fetal heart rate was frequently going down to 80 beats/per minute.  At 3.00 A.M. syntocinon drip was not stopped for fetal distress. It is not true that the complainant asked Dr.P.Malathi, Dr.Sudhakar or fourth opposite party to shift the deceased to Operation theatre to perform caesarian section for whatsoever reasons.  It is not true that Dr.P.Malathi, Dr.Sudhakar or fourth opposite party have declined to act on the request to do caesarian section as no such request was made at all.  In fact, because of the close and continuous monitoring by the third opposite party and the others present in the labour room they could not detect the abnormal uterine action at the earliest point of time. 

It is further submitted that at no point of time recording of Fetal hear rate at 80 beats per minute at any time as alleged by the complainant.  It is totally incorrect to say that the first complainant requested fourth opposite party, third opposite party and Dr.Sudhakar to shift the patient to the theatre and do immediate Caesarian section to avoid any risk to the mother and the baby.  There was no alarming situation contrary as alleged by complainant.  It is not true that fourth opposite party, Dr.Sudhakar or Dr.Malathi (third opposite party herein) have declined to act on the request to do Caesarian section as no such request was made at all.  It is submitted that the statements made therein are not correct.  It is not correct to state that fourth opposite party had asked the deceased to bear down the baby.  It is also not true to state that Dr.L.Sudhakar had administered any drug through Epidural Catheter after 3.20 a.m.   It is further submitted that Syntocinon drip was restarted is totally false and further the allegation that the fetal heart rate was 110 BPM, which was far less than the normal of 140 BPM is totally denied and the complainant is put to strict proof of the same.  The case sheet clearly shows that the fetal heart was between 130 to 138 beats per minute that is normal range till 3.30 A.M.  The contention that the deceased was in severe distress and was asked to bear down the baby is totally false.  The deceased was never asked to bear down the baby at 3-15 A.M. as she was not fully dilated.  It is further submitted that the deceased was never in distress as her vitals were continuously be monitored on various automatic monitors and also periodically monitored manually and there was never any request either to fourth opposite party or to Dr.Sudhakar or Dr.Malathi to do a Caesarian Section.  The vitals documented between 2.15 and 3-30 A.M. were within normal limits.  The complainant is put to strict proof of the contents in the complaint.

It is further submitted that it is not correct that the patient was going into shock with Cyanosis and was loosing consciousness at around 3-30 A.M. nor was there any request from the complainant or insistence for checking up blood pressure as stated in the complaint.  It is pertinent to submit that fourth opposite party, Dr.Malathi and Dr.Sudhakar were checking all vital statistics manually at frequent intervals in addition to monitoring through automatic monitors.  The blood pressure was 120/80 mm/HG. At that time contrary to as stated in the complaint.  IT is submitted that at about 3-40 A.M. Dr.P.Malathi noticed that fetal heart has come down to 120 to 110/mnts and was not restoring to baseline despite administering nasal oxygen and plain ringer lactate which was on flow.  At this state Dr.P.Malathi took a decision of performing an LSCS, and announced the same.  To this decision Dr.K.Srikar Reddy reacted strongly saying that he expected a normal delivery and now his wife is being taken for LSCS and questioned the decision.  Dr.P.Malathi explained him the reasons for such decision and explained him about the consequences of not doing LSCS.  He was not at all happy with the decision and walked out of labour room stating that he would call Dr.Rajesh Khanna to deal with the situation.  However, Dr.P.Malathi instructed to shift the deceased for LSCS.  The deceased was asked to move over the trolley for shifting into operation theatre but she was hesitant and refused to do so till her husband comes back.  After explaining her about the risk to the baby and after convincing her about the need of the surgery the deceased cooperated.  At this juncture, fourth opposite party informed the decision of caesarian section to Dr.Padmanabh Reddy.  First opposite party was informed that Dr.Malathi requested him to come to the hospital to take care of the baby.  With that information, Dr.Padmanabh Reddy rushed to the second opposite party hospital at 4 A.M. and then straightaway proceeded to baby resuscitation room and prepared everything and waited for the baby to arrive.  Through out this time, her vitals and fetal condition were being monitored continuously.  The fetal heart rate before shifting to the theatre was 120 beats per minute.  Hence at about 3.55 A.M. patient was wheeled into operation theatre with wedge under her right hip and flank with nasal oxygen and plain ringer lactate on flow.  It is not true that Dr.K.Srikar Reddy pleaded with fourth opposite party or third opposite party, or Dr.L.Sudhakar to rush the deceased to the theatre and do the best possible to save the deceased and the fetus as stated in the complaint.  It is neither true that third, fourth and fifth opposite parties were not responding to the situation properly nor true that Dr.K.Srikar Reddy asked Dr.Rajesh Khanna at 3.30 A.M. to come to hospital immediately as the condition of the deceased was worsening as stated in the complaint.  It is not true that Dr.K.Srikar Reddy screamed at fourth, fifth and third opposite parties asking to shift the deceased into the theatre immediately.  The deceased was shifted to theatre at about 3.55 A.M. contrary to as stated in the complaint.  The deceased was haemodynamically stable and was conversing with third opposite party and her husband.  It is not true that the vital time for resuscitation of the deceased and the fetus was lost as stated in the complaint, in fact there was no need for any resuscitation of the deceased at that point of time.

It is further submitted by first and second opposite parties that the patient was wheeled into operation theatre accompanied by fourth opposite party, Dr.Sudhakar and Dr.Malathi, Dr.Malathi noticed cyanosis just before shifting the deceased on to the operation table.  Dr.Sudhakar immediately applied facemask and started assisting respiration.  At this stage blood pressure was recorded and found to be lw.  After some time the cyanosis disappeared.  Dr.Sudhaker again connected all monitors, which were disconnected while shifting of the deceased.  At this stage Dr.P.Malathi went to inform the attendants about the condition of deceased and returned soon after that and Dr.RajeshKHanna followed her after a short while.  Dr.Rajesh Khanna went to the deceased and tapped on her cheek and asked how she is.  Is anything wrong to this the deceased pushed away the facemask and said “ No everything is OK”.  Dr.Rajesh Khanna asked her to show her tongue and she obeyed.  Dr.Sudhakar was about to put the facemask back on her face, the deceased developed convulsion.  Third opposite party checked for the Fetal heart and it was absent and third opposite party confirmed the same with CTG.  Dr.Padmanabh Reddy is not aware if Dr.P.Malathi has requested Dr.Rajesh Khanna to come into theatre to assist attending doctors in resuscitation as mentioned in the complaint.  However till such time there was no need for any aggressive resuscitation.  It is also not true that oxygen was being administered through nasal prongs at the time of entry of Dr.Rajesh Khanna into the theatre as mentioned in the complaint.  IN fact oxygen was being administered through facemask at that juncture as described above. Immediately after convulsions were stopped, Dr.Sudhakar intubated the deceased and started ventilating with 100% oxygen through Boyles.  It is not true that the first complainant screamed at the attending doctors to intubate the deceased as mentioned in the complaint.  The first complainant never entered the operation theatre until 5.50 A.M. when he was bought into the theatre to show the deceased body, well after declaring the death contrary to as mentioned in the complaint.  Hence the question of first complainant requesting any of the doctors to do caesarian section or otherwise does not arise at all.

By now the deceased was intubated, connected to Boyles and being ventilated as part of advanced cardiac life support.  An opportunity to shift the patient on the operation table never arouse.  The events were so sudden and so rapid that all attending doctors were busy providing emergency care.  Patient was wheeled into operation theatre accompanied by third opposite party, Dr.Sudhakar and fourth opposite party.  As the deceased was about to be shifted on to the operation table, she was found breathless, pulse was feeble, BP was 90/60 and Dr.Sudhakar attended to it immediately.  At 4.00 A.M. to fetal hear was faintly heard.  Third opposite party noticed cyanosis and Dr.Sudhakar immediately applied facemask and started assisting respiration.  At this stage, third opposite party went to inform the condition of the deceased to Dr.K.Srikar Reddy.  It is not true that the deceased was given oxygen through nasal prongs, as the deceased was being administered 100% oxygen through face mask and later with endotracheal tube.  Dr.K.Srikar Reddy never entered the operation theatre till 5-50 A.M.  Caesarian section could not be carried out as the deceased was being resuscitated.  It is not true that the complainant requested third, fourth and fifth opposite parties for not loosing the opportunity to save the deceased as complainant has never entered the operation theatre and every effort has been put by all the attending doctors to save the deceased in all possible ways.  Though early decision for caesarian section was made for the impending fetal distress due to the rapid development of maternal events leading to fetal collapse which gave third oppose party no scope to save the fetus.  At around 4.25 A.M. Dr.Shyamsunder entered the operation theatre.  On seeing Dr.Shhyamsunder, Dr.Rajesh Khanna started holding his hands and started crying saying that a catastrophe has struck his friend and pleaded to do something.  He threw the ventilating bag and dropped himself on the floor and buried his head in his lap and started crying.  Dr. RajeshKhanna sat on the ground behind the boyles, buried his face on to his knees and went on crying.  He never rose from there for almost about 40 mts.  Dr.Shyamsunder kept the defibrillator paddles on the chest and asked Dr.L.Sudhakar to switch on the paddle button on the defibrillator.  He gave a DC shock followed by Inj. Drenaline and atropine IV.  External cardiac massage was given by Dr.Shyamsunder and Dr.LSudhkar was ventilating with 100% oxygen at a ration of 5: 1.  It is not true that DC. Shock and drugs were not given by Dr.Shyamsunder to normalize heart rhythm as stated in the complaint.  ACLS was continued till 5.30 a.m. with no improvement in deceased clinical status.  At 5.30 A.M. o 6^th March, 2003 Dr.Shyamsunder has declared the deceased dead.  He announced that the cause of death was cardiopulmonary arrest antecedent to amniotic fluid embolism and third opposite party agreed with the same.  It is not true that case sheet was tampered with as stated in the complaint. 

It is submitted that that the cause of death informed to the relatives and Dr.Rajesh Khanna and the same was agreed upon by them.  It is further submitted that the cause of death and the antecedent cause of the death of the deceased was not mentioned in the Death Certificate or Death Summary of the deceased as the cause was clear and the same was already explained to the relatives and Dr.Rajesh Khanna and the same was agreed upon by them.  The contention that the same was not mentioned and the same was written at a later point of time in the case sheet is totally incorrect  and the complainants are put to strict proof of the same.  The further contention that the case sheet was tampered is totally incorrect.  It is submitted that the cause of death was mentioned clearly in the intimation given to the MCH.

First opposite party accompanied by Dr.Shyamsunder, Dr.Rajesh Khanna and Dr.P.Malathi went out from the theatre to inform this unfortunate news to Dr.Srikar Reddy, Mr.Ramakrishna Reddy, Dr.Vikranth Reddy and Dr.Madhavi.  Dr.Shyamsunder informed Dr.Srikar Reddy and other members of the family about the death and started consoling them.  Dr.Padmanabh Reddy was with the relatives of the deceased from 5-30 A.M. till 7.00 A.M. along with Dr.Shyamsunder and Dr.Rajesh Khanna.  Opposite parties waited for about 30 minutes until the relatives settled down from initial grief and then first opposite party along with Dr.Shyamsunder  in the presence of Dr.Rajesh Khanna suggested to Mr.Ramakrishna Reddy that they would like to inform police and arrange for a post-mortem.  Dr.Vikranth Reddy enquired about postmortem with females and relatives deliberated the decision and said “NO”. 

First opposite party have ascertained the cause of death as amniotic fluid embolism and cardiopulmonary arrest from Dr.P.Malathi and Dr.Shyamsunder.  As the cause of death was clear and was informed to the relatives and Dr.Rajesh Khanna, and the same was agreed upon by them.  However in view of social framework, usual repulsion of autopsy due to disfigurement and the circumstances at the demise of loved ones they could not implement their decision of informing police and organizing an autopsy in view of the fact that the relatives had refused as stated supra.  Usually first opposite party declined the allegations that a case sheet was tampered with at any point of time and also decline that autopsy was not done with any criminal intension to suppress the real cause of death as mentioned in the  complaint.  First opposite party would like to state that father of the ceased Mr.Ramakrishna Reddy is a Senior Practicing Lawyer and husband of the deceased Dr.Srikar Reddy, Dr.Vikranth Reddy (brother of the deceased) and Dr.Madhavi are medical doctors and were being assisted by Dr.Rajesh Khanna who is a practicing anesthesiologist.  All of them are well aware of the fact that an autopsy can and should be done if there is a doubt about the cause of death.  They also know that no one can stop them from informing police and make a case of inappropriate medical practices and could have easily arranged for an autopsy.  It goes on to prove beyond doubt that Dr.Srikar Reddy, Mr.Ramakrishna Reddy, Dr.Vikranth Reddy, Dr.Madhavi Reddy were convinced of the cause of death.  The fact that Dr.RajeshKhanna was in operation theatre from 4.10 A.M. till the time of declaring death and was present along with the team (Dr.Shyamsunder and Dr.Padmanabh Reddy) that declared the news to the relatives and did not inform the police about possibility of an inappropriate medical practice goes on to prove beyond doubt that the cause of death was amniotic fluid embolism.  As a responsible practicing Anesthesiologist Dr.Rajesh Khanna would not have remained silent when the cause of death was being explained to the relatives of the deceased more so he being a family friend of Dr.Srikar Reddy and Mr.Ramakrishna Reddy.  If there was an element of doubt about inappropriate medical practice it would be amoral, professional responsibility in addition to being responsibility of a good citizen, to inform relatives and police about such inappropriate medical practice along with insisting on arranging an autopsy.  It is further submitted that the deceased was given analgesia and not anesthesia as contended in the complaint. 

It is further submitted that Shalini Maternity Hospital is well equipped with all necessary equipment and drugs to deal with the complications of epidural analgesia.  All the emergency drugs and resuscitation equipment were available in labor room on the intervening night of 5^th and 6^th March,2 003,  without any prejudice, would like to state that Dr.Sudhakar and Dr.Malathi in accordance with their professional obligations and duty have ascertained the availability of all such equipment and emergency drugs in labor room in presence of another anesthesiologist (Dr.Rajesh Khanna).  It is not true that the patient was kept in supine position as stated in the complaint.  Patient was kept in lateral position although the labor except while administering top-up of epidural analgesia where she was made to sit and while examining PV 9 in supine position).  Wedge was kept under her right hip and flank while the deceased was being shifted to operation theatre and all through the resuscitation till she was declared dead, contrary to as mentioned in the complaint.  It is not true that the consultants and fourth opposite party have acted in a rash and negligent manner in positioning the deceased as stated in the complaint.   It is not true that after shifting the deceased to operation theatre, immediate steps ere taken to resuscitated her.  The question and need of resuscitation arose only after noticing cyanosis in the operation theatre.  As soon as cyanosis was noticed, prompt and appropriate resuscitation measures were taken including intubation and supply of 100% oxygen through boyles apparatus.  In any given circumstances it is unlikely that 3 well qualified and experienced doctors would sit next to a dying patient and do nothing to help her as mentioned in the complaint.  It is not true that the consultant anesthesiologist has acted in a rash and negligent manner in not doing endotracheal intubation to supply 100% oxygen as mentioned in the complaint.  It is not true that the deceased was not attended properly in the operation from 3.40 A.M. to 4.15 A.M. in accordance with the case sheet and as stated in the complaint.  Deceased was shifted into the theatre at 3.55 A.M. and accompanied by consultants and fourth opposite party.  Opposite parties were constant monitoring the patient.  The complainant may be presuming that nothing was done between 3.40 A.M. to 4.15 A.M.  The consultants were busy in attending the patient and probably felt documentation is secondary to attending a needy patient.  There was no time tosh fit the patient from the trolley to the operation table in view of rapid events that followed after initial cyanosis and kept everyone busy attending the deceased all through till the death was declared.  It is the consultant Obstetrician and Consultant Anesthesiologist decision to deliver the baby by whatsoever means.  They have taken a decision not to do so.  The fourth opposite party’s role as Resident Doctor is to assist them in whatever procedure they might have adopted. 

It is not true that deceased was not monitored on a minute to minute basis as stated in the complaint.  As stated earlier deceased was almost always accompanied by both the consultants and fourth opposite party.  Deceased was taken into operation theatre to perform LSCS.  However the events that followed were very rapid and has not given opposite parties an opportunity to shift the patient on to the operation table leave alone documenting every effort that has been made to save the deceased.  The complainant was not witnessing what was being done to save the deceased.  The complainant is apparently making his conclusions basing on the medical records.    The consultants and the Resident Doctor have not given importance to document each and every event as against putting every effort to save the deceased.  It is not true that defibrillator was not in working condition and emergency drugs were not available.  As mentioned earlier defibrillator was in working condition and all emergency drugs were available in labour room and operation theatre.  It is not true that cyanosis, hypotension, bradycardia, loss of consciousness and convulsions leading to cardiac arrest occurred when labour was induced with syntocinon drip, drugs like Busopan, Drotin and Epidosin given for cervix dilation and acceleration of labour and epidural analgesia for relief of labour pain as stated in the complaint. 

It is submitted that the complainant has stated various possible complications which has caused death of his wife.  The complications as mentioned are:

          I         High block/total spinal block

          II        Drug toxicity

          III       Vasovagal shock

          Shalini Maternity Hospital i.e., second opposite party’s role is limited to providing facilities and infrastructure to the consultants for providing healthcare services to their patients.  The further contention that the opposite parties had not done resuscitation measures promptly is totally false as already explained.  In fact everything possible and required was done and measures were taken to save the life of the mother and the fetus.  Deceased was shifted into the theatre at 3.55 A.M. and accompanied by Dr.Sudkahar, third and fourth opposite parties.  They were constantly monitoring the patient.  Opposite parties were busy in attending the patient and probably the consultants felt that documentation is secondary to attending a needy patient.  The events occurred so suddenly on the trolley, opposite parties could not shift the deceased on to the operation table as it causes delay in resuscitation.  Though an early decision for performing caesarian section was made even before fetal distress (normal range 110-160 beats/minute) could  set in,  third opposite party could not perform caesarian section due to rapid and successive events that followed.  It is also submitted by first and second opposite parties that the deceased was treated free of charge as the first complainant husband happened to know fifth opposite party very closely and that no money was paid and therefore they are not entitled to any compensation.  The process of clinical care is not the responsibility of first, second and fourth opposite parties as such they are not responsible for any consequences.  They further contend that the first complainant is a member of Indian Foreign Service and the second complainant is a leading Advocate and are not expected to be taken care of their deceased daughter in their old age and therefore compensation of Rs. One crore sought by them is not sustainable.  They further contend that there is no medical negligence on their behalf and seeks dismissal of the complaint with costs.

          Third opposite party filed counter reiterating the facts of the counter of first and second opposite parties and further submitted that on the recommendation of Dr.V.S.Rajesh Khanna, the first complainant approached this opposite party expressing dissatisfaction over the facilities in Jaya Nursing Home, took a decision to shift his wife to the first opposite party’s hospital and third opposite party contend that they did not accept any payment out of professional fraternal feeling.

          Third opposite party also submits that the patient was admitted into the hospital at 11.45 P.M. and third opposite party examined the patient in the labour room.  At 12.05 A.M., the third opposite party found the patient was in active labour with intact bulging bag of membranes without draining and cervical dilatation of 4 cm.  She was diagnosed as having HROM and consequently third opposite party did artificial rupture of membrane to see the  colour of liquor which was clear at 12.20 a.m..  Acceleration of labour is an accepted mode of management and labour room staff has administered the drugs sequentially and deceased was never kept in supine position throughout but kept in lateral position which is in accordance with the routine practice to prevent hypotension and to increase the utero-placental circulation.  Fetal heard was monitored continuously with the electronic fetal monitor and it was documented within normal range of 132-138 beats/minute upto 3.30 A.M.  She was frequently updating the progress of the labour, status of the fetus and also of the mother.  At 3.00 A.M. third opposite party noticed too frequent uterine contractions so to avoid further hyper stimulation, Syntocinon drip was stopped.  It was also because of her close and continuous monitoring, she could detect the abnormal uterine action at the earliest.  She denies that the deceased was forcibly asked to bear down at 3.15 A.M.   The patient was coached and encouraged to bear-down at 3.30 A.M. and the patient was never in distress as her vitals were continuously monitored on various automated monitors and periodically monitored manually.  Opposite parties also contend that the deceased never requested her or fourth or fifth opposite parties  to do a caesarian section.  Till 3.40 A.M. the vitals documented by this opposite party were within normal limits.  The blood pressure was 120/80 mm/Hg, fetal heart rate was 138 BPM, Maternal pulse rate 76 PM with normal temperature.  Third opposite party submits that at 3.40 a.m. she found that fetal heart rate was 120 BPM which persisted to 110-120 BPM in spite of routine resuscitative procedures.  Suspecting impending fetal distress the decision for cesarean section was made and duly informed the fourth and fifth opposite parties and first complainant were informed.  The first complainant questioned her decision and the reasons were explained to him and the first complainant wanted to take opinion of Dr.V.S.Rajesh Khanna and walked out of labour room.    Third opposite party convinced about the need of the surgery and through out her vital and fetal conditions were monitored.  At about 3.55 A.M. the patient was wheeled into the operation theatre with wedge under her right hip and flank with oxygen and plain ringer lactate on flow.  It took 15 minutes to convince first complainant for cesarean section and after shifting into the theatre the patient suddenly became breathless, developed cardio-vascular collapse and cyanosis and immediately appropriate resuscitative measures were started by the team, headed by the anesthetist. 

          Third opposite party denies all the allegations of the complainant and submits that at about 4.10 a.m. Dr.V.S.Rajesh Khanna assisted fifth opposite party in the resuscitative process along with fourth opposite party and the first complainant did not accompany Dr.V.S.Rajesh Khanna into the theatre.  At 3.40 A.M. the patient was conscious with BP 100/70 mm of Hg, pulse rate 80 beats/min, fetal heart rate was 120 BPM.  Despite best efforts of fifth opposite party, assisted by the other doctors of the team, Cyanosis progressed and persisted.  Dr.V.S.Rajesh Khanna came into the theatre and helped in the resuscitation efforts and still the patient had cardiovascular collapse.  From 3.55 AM to 4.15 AM the deceased suffered hypoxia for 20 minutes culminating in convulsions and cardiac arrest.  At about 4.30 AM the deceased was being attended by upon by fourth, fifth, sixth opposite parties and Dr.V.S.Rajesh Khanna, as well as third opposite party and the condition of the deceased became grave with persistent cyanosis and appropriate advanced resuscitative measures were performed.  The patient was declared dead at 5.30 AM and the cause of death was mentioned as  “Amniotic Fluid Embolism” in the case sheet and the MCH intimation form.  She denies that this cause of death was added as an after thought and also that they did not take steps to perform autopsy.  The complainants are educated and had they asked for autopsy the opposite parties could have got it done.  She submits that in the presence of Dr.V.S.Rajesh Khanna they suggested to second complainant that they would like to inform the police and arrange for an autopsy but patients attendants state ‘NO’ and also become violent and abusive.  She denies that the case sheet was tampered with and also denies the allegations of the complainants in their complaint about the administration of drugs and about improper monitoring after epidural analgesia, about the position of the patient in left lateral position and that endotracheal intubation to give 100% oxygen was not done together with other allegations made by the complainants in their complaint with respect to medical negligence.

          Third opposite party submits that informed consent obtained before the administration of epidural analgesia and that standard protocol for labour augmentation and appropriate drugs for augmentation for cervical dilation were administered.  Drug doses, frequency and route of administration of these drugs is as per the accepted medical practice.  She denies that Syntocinon drip was started at 3.00 A.M. because of fetus distress but submits that it was because of frequent uterine contraction.  Third, fourth and fifth opposite parties are present between 3.45 and 4.15 a.m. and the deceased was shifted to operation theatre only for performing cesarean.  Amniotic Fluid Embolism is a complex disorder, a known rare complication of pregnancy during labour, with no known measures to predict or prevent its occurrence, with a great individual variation in the clinical picture, appearing in late stages of labour, or immediately after postpartum, with rapid onset of hypotension, hypoxia and consumptive coagulopathy.  The diagnosis is contingent upon careful exclusion.  Lab tests done to diagnose the amniotic fluid embolism lack the sensitivity and specificity.  There is no data that any type of intervention improves maternal prognosis with amniotic fluid embolism.  Management of the amniotic fluid embolism is usually a supportive care.  In mothers who are hemodynamically unstable and suffered cardiac arrest the role perimortem cesarean section is vey controversial and speculative.  Third opposite party also denies the other alleged complications by complainant like high block, drug toxicity, vasovagal shock etc.

          Third opposite party further contends drug doses frequency and route of administration of drugs were as per the accepted medical practice and vasovagal shock is one of the anesthetic/obstetric complications which is usually a reversible complication by appropriate resuscitative measures.  The deceased was kept in left/right lateral position or tilt by a wedge through out the stay in the hospital to prevent supine hypotension and vasovagal syncope and mother and fetus were monitored appropriately.  She further denies all the other allegations made by the complainants in their complaint and reiterates what the first and second opposite parties has stated in their counter with respect to the compensation that has been sought for by the complainants.  She submits that there is no medical negligence on their behalf and seeks for dismissal of the complaint with costs.

          Fourth opposite party filed counter reiterating the facts of the counters of first, second and third opposite parties with respect to the treatment accorded and submitted that there was no negligence or deficiency of service on behalf of the opposite parties.  It is pertinent to note that fourth opposite party had expired during the pendency of this complaint. 

          Fifth opposite party filed counter reiterating the facts of first, second and third opposite parties with respect to the facilities of the nursing home and with respect to the admission of the patient.  He submits that he  received a telephone call from Shalini Nursing Home at 11.50 P.M. informing him about a patient that needs labour analgesia.  Immediately he received another call from Dr.Rajesh Khanna informing him that Dr.K.Srikar Reddy’s wife was admitted in Shalini Maternity Hospital and requested him to come and provide labour analgesia.  Fifth opposite party submits that Dr.Rajesh Khanna and first complainant were college mates of this opposite party and they were also close friends and he knew them well for the past seven years and therefore he accepted the call as a friend rather than a professional provided analgesia services free of cost.  Fifth opposite party arrived at hospital at 12.15 AM and went into the labour room who found first complainant together with fourth opposite party and other labour room staff along with the patient and Dr.Rajesh Khanna entered the labour room and the patient and the first complainant signed the consent form for labour analgesia.  All the complications were explained to them and after completing the pre-anesthesia check up, fifth opposite party checked up the emergency equipment, drugs and preparation for labour analgesia.  During this process this opposite party over heard third opposite party explaining to the patient about the advantages of labour analgesia and Dr.Rajesh Khanna recommends the same.  After thorough scrubbing and under strict aseptic precautions, this opposite party administered local anesthesia with 2 ml of 1% Lignocaine at L3 – L4 space in sitting position and after ensuring analgesia effect 18G Tuohy needle was introduced into L3 – L4 space and epidural space was identified by loss of resistance technique using 2 ml of air with glass syringe.  The epidural space was obtained at 5 cms, and after ensuring that no fluid/blood was coming out, this opposite party introduced epidural catheter with the bevel of the needle in caudal direction and fixed at 8 cms i.e., the catheter was lying only 3 cms in the epidural space.  Once again fifth opposite party waited for 5 minutes and confirmed that there were no haemodynamic changes, neurological symptoms and motor block.  Then this opposite party administered 10 ml of 1% lignocaine with 50 micrograms of Fentanyl slowly over a period of 10 minutes.  This opposite party kept the patient in lateral and propped up position and provided oxygen supplementation as this is a routine practice.  During all this first complainant and Dr.Rajesh Khanna were present next to the patient and first complainant provided moral support to the deceased.  Third opposite party did an artificial rupture of membranes and instructed to start 5 units of Syntocinon in drip at the rate of 8 drops/minute and the same was implemented.  After finding that the deceased was comfortable, at about 00.50 AM both first complainant and Dr.Rajesh Khanna left the labour room stating that they are going for dinner.  At about 1.00 AM the deceased complained pain and she was again given a top-up dose of 4 ml of 0.25% of Bipuvacaine after ensuring that there was no aspiration of cerebrospinal fluid/blood to ensure patient controlled analgesia.  Fifth opposite party has also continuously monitored BP, PR and SaO2 through monitor as well as manually at regular intervals.  At  1.30 the patient once again complained of pain and third opposite party did a pervaginal examination and informed that cervix was afaced and dilated to 5-6 Cms with regular fetal heart rate.  Hence this opposite party kept the deceased in sitting position and administered second top-up dose of 4 ml of 0.25% Bipuvacaine after confirming that there was no aspiration of CSF and kept the deceased to remain in sitting position for about 5 minutes.  After 5 minutes the deceased was made to lie down in lateral and propped up position and at 1.40 AM first complainant came back to labour room and conversed with the patient and at 2.00 AM the deceased once again complained of pain and she was administered 6 ml of 0.125% Bipuvacaine via epidural catheter after keeping the deceased in sitting position and after confirming that there was no CSF/Blood in the catheter again she was made to lie down in lateral position. All the vital parameters were checked.   At 2.30 AM the deceased complaint of pain once again.  The deceased was again kept in sitting position and after confirming that there was no CSF/blood in catheter, another top-up dose of epidural analgesia of 4 ml of 0.125% Bipuvacaine was administered and at this stage also the patient was conversed with the first complainant.  At 2.50 A.M. Dr.Rajesh Khanna called this opposite party on cell phone to verify the condition of the deceased and informed him that the deceased was stable and labour is progressing well.  This was the last top-up does of analgesia that was given to the deceased at 2.30 AM and thereafter no further dose  of analgesia was given to the deceased. 

          Fifth opposite party further submits that at about 3.30 AM she asked the deceased to bear down the baby by voluntary efforts and first complainant who was sitting beside the deceased provided moral support and asked her to bear down the baby.  The vital statistics were stable and BP was 120/80, PR 76/minute.  The labour progressing uneventfully till about 3.40 AM and at that point of time fifth opposite party notice that fetal heart rate has come down to 110 from 120 per minute  and at 3.45 AM fifth opposite party has decided to perform emergency LSCS and informed the same to this opposite party.  The first complainant reacted strongly saying that he expected a normal delivery and also reacted against the deceased for not cooperating.  The deceased was hesitant and refused to go till her husband comes back and third opposite party explained the deceased about the risk to the baby then she agreed.  At 3.55 AM the deceased wheeled into operation theatre with a wedge kept under her right hip and flank.  Fifth opposite party administered oxygen via the facemask with Bain’s connected to Boyle’s machine which delivers 80-100% oxygen.  This opposite party noticed dropping of oxygen saturation and appearance of cyanosis.  The deceased was breathless but responding to verbal commands.  Fifth opposite party assisted her breaths face mask with bains connected to Boyle’s.  At 4.00 AM there as a drop in the level of consciousness with persistent cyanosis.  This opposite party administered oxygen with bains circuit by mask ventilation which delivers 100% oxygen.  Six opposite party informed about the condition of the patient.  Fifth opposite party noticed that heart rate was 40/per minute and BP was at 80/50 mm/Hg. And requested fourth opposite party to give one ample of Inj. Atropine and to start Dopamine infusion by adding 2 ampoules of Dopamine in one bottle of normal saline and run it at 22 drops/minute and she did so accordingly.  Saturation improved and cyanosis regressed and the deceased was responding to verbal commands.  At 4.10 AM Dr.Rajesh Khanna entered the operation theatre but the first complainant not present.  At this stage the patient went into convulsions which were tonic in nature and at 4.20 AM the deceased had a cardiac arrest and fifth opposite party gave Inj. Atropine 0.6 and Adrenaline 2 mg diluted to 5 ml injections through endotracheal tube and asked fourth opposite party to give 1mg Adrenaline and 0.6 mg of Atropine through IV and she did accordingly.  Fifth opposite party also gave external cardiac massage and breaths were given by Dr.Rajesh Khanna.  At 4.25 AM sixth opposite party entered the operation theatre and immediately after seeing him, Dr.Rajesh Khanna broke down and fifth opposite party took the ventilating bag and started ventilating.  Sixth opposite party gave DC shock of 320 Joules followed by Inj. Adrenalline and Atropine IV and external cardiac massage.  Once again fifth opposite party ventilating with 100% oxygen at a rate of 5:1 as per the ACLS protocol.  At 5.10 AM this opposite party administered 50 ml of Sodium bicarbonate to combat metabolic acidosis which is usually presenting patients on ACLS with cardiac arrest lasting for more than 20 minutes.  ACLS was continued till 5.30 AM with no improvement in patient’s clinical status and thereafter sixth opposite party declared the deceased dead and announced that the cause of death was cardiopulmonary arrest antecedent to Amniotic Fluid Embolism.  The same was mentioned in the case sheet and MCH certificate.  An autopsy was refused.  Thereafter fifth opposite reiterated what other opposite parties mentioned in their counters with respect to the line of treatment given. 

Fifth opposite party reiterates in his counter the drugs administered to the deceased keeping her in sitting position as follows:

          It is submitted that there was no drug toxicity in the case of the deceased.  The initial local anesthetic drug given was Lignocaine.  The maximum limit of this drug is 2.5 ml/Kg. (Regional anesthesia, Collins P.No.1258).  Maximum recommended dosage is 200 mg without adrenaline and 500 mg with adrenaline.  (Table 10.4 page No.181 Wylie 6^th Edition)  The permissible does in the case of the deceased was 2.5x60=150 mg. 10 ml of 1% lignocaine contains only 100 mg which is far less than the recommended high dosage.

          The next drug was Fentanyl 50 micrograms single dose.  Which is not at all a high dosage because the initial dose is 50 -100 micrograms with the loading dose.  (internal practice of anesthesia Vol.1)

          The next drug as Top-up dose given was Bipuvacaine.  The total amount of drug used was 32.5 mg in the case of the deceased.  The maximum recommended dose is 2 mg per Kg upto 150 mg for the first 4 hrs and 400 mg over the first 24 hours.  (Table 10.4 Page No.181 Wylie 6^th Edition) It is therefore submitted that the allegation of over dose of Bipuvacaine is totally baseless, unfounded and unwarranted.

          He denied all further allegations made by the complainant and reiterated his line of treatment.  There was no High block/Total spinal block and if dural puncture is done by 18G epidural needle the CSF will gush like a tap of water and this was not so in this case.  If the epidural catheter was improperly placed, the first sign that would appear is reflux of Cerebro spinal fluid or blood along the catheter.  There was  nothing like that in the case of the deceased and the last dose of Bipuvacaine was given at 2.3 AM after which the patient was conversed to the first complainant and if there was total blockage she could not have conversed to the first complainant.  He further denied the allegations of vasovagal shock and submitted that if there was vasovagal attack, it would have accompanied by bradycardia which is not so in the present case.  All through first complainant was sitting by the side of deceased and was conversing with her.

          Fifth opposite party submits that Amniotic Fluid Embolism is a cause of death and it is a rare obstetric emergency in which amniotic fluid, fetal cells, hair or other debris enter the maternal circulation cause cardio respiratory collapse.  As per the statistics incidence of amniotic fluid embolism is 1 : 8000-30,000.  Amniotic Fluid embolism occurs during labour.  The mortality rate is as high as 85%.  The following signs and symptoms are indicative of possible Amniotic Fluid Embolism:

§         Hypotension:

§         Dyspnea

§         Seizure

§         Cyanosis

§         Fetal bradycardia

§         Cardiac arrest

Fifth opposite party thus established beyond reasons that the deceased died due to amniotic fluid embolism and that there is no specific therapy for amniotic fluid embolism and the treatment is only supportive care i.e., the patient has to be provided oxygen to maintain oxygen saturation and initiation of cardio pulmonary resuscitation if the patients arrests and also treatment of hypotension.  Fifth opposite party further submits hat the patient was provided 100% oxygen with face mask through Bain’s circuit connected to Boyle’s machine.  Hypotension was being corrected with fluids both crystalloid and colloid.  The deceased was given 1 ampoule of Inj. Atropine and dopamine infusion by adding 2 ampoules of Dopamine in one bottle of normal saline at the rate of 22 drops per minute.  At one stage saturation improved and the patient was responding to verbal commands.  Fifth opposite party had put all his best efforts to save the life of the deceased but could not since the AFE not known.  He submits that he shares the grief of the complainants and his friend Dr.Rajesh Khanna being his friend and college colleagues and that the figure of compensation is excessive and alleged damages claimed are of remote nature and cannot be granted and that he is not liable to pay any amounts of compensation since there is no negligence on their behalf. 

Complainants filed evidence affidavits and Exs.A1 to A20 were marked on their behalf.  Opposite parties filed affidavits by way of evidence and Exs.B1 to B25 were marked on their behalf.  PWs 1 and 2 deposed on behalf of the complainant and RWs 1 to 4 deposed  on behalf of the opposite parties.  Sixth opposite party filed affidavit by way of evidence but did not choose to come to witness box and therefore his evidence was eschewed. 

The complainants filed affidavit by way of evidence and reiterated the facts in the complaint.  Ex.A1 is a case sheet issued by Shalini Nursing Home specifying the line of treatment, the cause of death, nurses record and partogram.  Ex.A2 is the death certificate issued by fourth opposite party.  Ex.A3 is the death summary issued by third opposite party.  Ex.A4 is the record of ante-natal check ups with Dr.Suvarna Ramaswamy.  Ex.A5 is the case sheet of Jaya Nursing Home.  Ex.A6 is the SSC certificate of the deceased.  Ex.A7 is the intermediate certificate.  Exs.A8 to A13 are educational certificates of the deceased i.e., B.E, Java Certification in complete Java issued by Java World, Certificate in Unix, C,C++, OOPS, GRE Report of scores, TOEFL respectively.  Ex.A14 is MS certificate issued by Cleveland State University, USA.  Ex.A15 and A16 are the income tax returns of the deceased.  Ex.A17 is the salary certificate.  Ex.A18 is the CD and Exs.A19 and 20 are the tapes.

Opposite parties filed affidavits reiterating the facts in their counters.  Ex.B1 is the original case sheet issued by Shalini Maternity Hospital.  Ex.B2 is the death Certificate of Shalini Hospital sent to MCH.  Ex.B3         is the Acknowledgement in respect of handing over of copies of documents dated 10.3.2003.  Ex.B4  is the acknowledgement dt.11.3.2003 acknowledging receipt of   death Summary.  Ex.B5 is the letter dated 13.3.2003 reflecting receipt of death report by the  Sub Registrar of Births & Deaths.  Ex.B6 is the letter dated 11.4.2003 reflecting acknowledgment of receipt of  copies of the case sheet.  Ex.B7 is the letter dated 6.5.2003 acknowledging receipt of case sheets.  Ex.B8 is the letter dated 24.5.2003 acknowledging receipt of copies of the Case Sheets.  Ex.B9 is the letter No.APMC/DC/C.18/2003, dt.11.2.2004 of the Registrar, A.P.Medical Council, Hyderabad.  Ex.B10 is the certificate dated 10.1.1989.  Ex.B11 is the certificate dated 30.9.1988.  Ex.B12 letter dated 17.6.1994.  Ex.B13 is the letter of Office Supt. Govt. Maternity Hospital dt.30.12.2003.   Ex.B14 is the copy of affidavit of Dr.V.S.Rajesh Khanna.  Ex.B15 is the copy of telephone bill with detailed statement. ( filed by O.P.5) Ex.B16 is the delivery Challan dt.26.1.2001.   Ex.B17 is the invoice dated 31.12.2004 of Sree Agencies Enterprise to Shalini Hospital.  Ex.B18 is the quotation dated 21.10.2000.  Ex.B19 is the technical Information.  Ex.B20 is the  bill dated 24.4.2001 of Agilent Technologies.  Ex.B21 is the delivery Challan dated 23.4.2001.  Ex.B22 is the copy of invoice dated 31.1.2001 of JDS Medison India (P) Ltd.  Ex.B23 is the letter dated 25.12.2000 of JDS Medison India (P) Ltd., to   Dr.Padmanabh Reddy.  Ex.B24 is the price Quotation for Convex Desk Top Ultrasound of JDS, Medison India (P) Ltd. Ex.A25 is the policy copy. 

Since the case pertains to Medical Negligence, we do not wish to go into the taped conversations since it is inadmissible evidence.  Already this Commission has given a finding in C.D.I.A.No.1646 of 2005 that this evidence is inadmissible in case of medical negligence in consumer forum. 

The brief point that falls for consideration is whether there is any deficiency of service on behalf of the opposite parties in treating the patient and if the complainants are entitled to the compensation sought for in the complaint?

First, second and third opposite parties filed written arguments.  The learned counsel for the complainants filed written arguments and also addressed his arguments at length. 

Heard the counsel for the opposite parties no.1 to 5 also at length.  It was brought  to the notice of this Commission that fourth opposite party died during the pendency of this complaint and it was contended that since it is a medical case no cause of action can arise against the doctor who has died during the pendency of the complaint. 

1)     Is there any negligence with respect to taking CONSENT?

There are several issues which has been raised by the complainants with respect of medical negligence and we address them as follows. 

The first contention of the complainant is that the consent form was a generalized form taken during the time of admission and  not taken prior to epidural analgesia and that pre-anesthetic check up was not done to ascertain whether  the patient was fit to undergo labour analgesia or not and that the same was administered without proper consent.  The learned counsel for the complainants submitted that the consent of the first complainant was mechanically obtained without explaining the procedure and the consequences of administering epidural analgesia and that it was a generalized consent.  It is the case of the opposite parties that the first complainant being a qualified medical doctor though not practicing had signed the consent form for labour analgesia in the presence of Dr.Rajesh Khanna after having elaborate discussions with opposite parties.  The fourth opposite party was a qualified Obstetrician who had taken the consent and this contention supported by third and fifth opposite parties.  It is the case of the opposite parties that the first complainant and the patient was explained about the procedures and advantages and disadvantages and also the complications of labour analgesia.  We have gone through the deposition of the first complainant i.e., PW1 in which he deposed as follows:

“It is true to suggest that I have signed a consent form.  My wife has also signed the consent form but the consent form is a generalized consent and it is not particular to epidural analgesia.  In the consent form epidural analgesia was not there and it was subsequently added.  I do not remember whether I have stated so in the complaint or not.  I signed on the blank form having trust on the doctors in the hospital.”

We have perused the original consent form which is  a part of Ex.B1 and also the copy filed as a part of Ex.A1 filed by the complainants.  The consent form states as follows:

“ AUTHORIZATION FOR MEDICAL AND/OR SURGICAL TREATMENT

                                                                        Place:  S.M.H.

                                                                        Date:  5-3-03.  Time: 11.45 P.M.

1.  I hereby authorize, Shalini Hospital to perform the following operation or procedure on:

Name of the Patient:  Mrs.Srilatha     Hospital No. _________  Age: 25  Sex: Female, Name of Operation or Procedure: Epidural analgesia. 

            2.  The nature of my condition and the hazards of the operation or procedure including Biposy and any unwanted untoward complications that may arise have been explained to me by my Physician(s)/Surgeon (s). 

            3.         I consent to the administration of anaesthesia may deem advisable in my case.  I also consent to the administration of any other drug relevant to the procedure.

            4.         I further authorize the said Physician(s)/Suregon(s) to perform such additional operations or procedures including the administration of a blood transfusion or blood plasma as they or he may consider reasonably necessary or proper in the event of any emergency or if any unanticipated condition should be discovered during the course of the operation. 

            5.         I hereby authorize the Hospital, its agents or devisees to dispose off any removed tissue or amputated member of my body as a result of the surgical operation in any manner deemed proper by the Hospital.

            6.  All the above points have been explained to me in the language which I understand.

Name of the Patient (Type or Print):                          Signature of the Patient:

                 Srilatha                                                                              Sd/-

If the Patient cannot sign or minor
        Spouse, Parent or Guardian:   K.Srikar Reddy

Relationship to Patient:                      Hyderabad

Witness: ______________________________________________________

Address:   H.No. 3-5-1092/7,
                   Sri Venkateswhara Colony
                   Narayanguda, Hyd – 29

                                                                                    For  SRISHTI ASSOCIATES

                                                                                                            Sd/-

                                                                                    (Dr.M.Padmanabh Reddy)
                                                                                             Proprietor

          It is apparent from the above consent form that both patient and first complainant have signed it and the name of the patient and the procedure is written and it is also pertinent to note that the first complainant is a  qualified doctor and admittedly Dr.Rajesh Khanna who has referred the first opposite party hospital to the complainants is also an anesthetist.  From the aforementioned signed consent form and the depositions, it is established that the first complainant was aware of the procedures of epidural analgesia and cannot state that he was unaware of the risks and complications, being a medical graduate himself, and also being referred by his own classmate Dr.Rajesh Khanna who is also an anesthetist and who was already in touch with the opposite parties.  Therefore the contention of the complainants that the consent was not informed is not sustainable. 

2)    Is there any negligence with respect to monitoring of  anesthesia?  Was there any drug toxicity?

The second contention of the complainants is that there was no proper monitoring.  RW4 did not ascertain the level of anesthesia before and after giving the dose.   Top up doses of Bupivacaine were given indiscriminately every 30 minutes whereas the drug is normally given after 60 to 90 minutes depending on the level of Motor/Sensory level block.  Opposite parties not only gave the drug in much shorter duration they have not even verified the level of Motor/Sensory level block to check whether the same is adequate or inadequate or excessive.  Fifth opposite party did not do continuous monitoring of pulse, blood pressure and respiratory rate every five minutes and monitors like pulseoxymeter and electro-cardiogram monitor etc., were not used.  Fifth opposite party did not continuously monitor the deceased for complications  normally associated with epidural analgesia like chance migration of epidural catheter in to dural space or dural puncture, consequent to which high spinal/high epidural block was not recognized.  First and second opposite parties did not check regularly monitor properly  the fetus heart rate and progress of labour whereby early distress signs were not noticed.  The learned counsel for the complainants relied on the medical literature in Williams Obstetrics, 21^st Edition, Page 375 and in Epidural Analgesia, 1978 published by Philip R.Bromage, page 237 & 238 in which it is stated as follows:

The amount of local anesthetic needed to keep the segmental level of analgesia constant is about one half the initial induction dose, and this “top up” dose needs to be given when the upper level of analgesia has receded one or two dermatomes…………Segment-time diagrams are constructed for the onset and decay of analgesia in each patient, a pin-prick being used to determine the upper and lower margins of sensory analgesia…………the total duration was three hours, but the upper level of analgesia began to recede at 90 minutes after the block was complete, and it has fallen two dermatomes 10 minutes later.  This point, the point of “recession of two dermatomes” is the relevant clinical landmark at which a reinforcing dose of local anesthetic must be injected in order to maintain an effective level of surgical analgesia”

The learned counsel for the complainants further argued that PW2 deposed in his affidavit evidence that the level of anesthesia should be ascertained before and after giving the dose.  Top up doses should be administered only if the level of anesthesia comes down by two segments which will be normally after 90 minutes to 2 hours and that no recordings have found in the case sheet Ex.A1. 

The learned counsel for the fifth opposite party contended that there was continuous monitoring and denied that pre-anesthesia check up was not conducted.  It is noted in the case sheet at page 5  as “Pt.C/C” which means patient conscious and coherent, “ASA Gr.1,” means as per the standards of American Society of Anesthesiology Grading, the patient is graded as No.1.  There was a recording of B.P. also showing BP 120/80.  Fifth opposite party conducted pre-anesthetic checkups and then only administered Epidural analgesia and thepatient was continuously connected to the Pulseoxymeter, ECG and NIBP monitor and it is the case of the fifth opposite party that he adjusted the upper and lower limit alarms for all parameters to monitor the deceased continuously and denies that there was no pre-anesthetic check up.

We have observe from the record that fifth opposite party has stated that he has given the following doses at the following specified times.

           Fifth opposite party also submitted that the permissible dose in the case of the deceased is 2.5 mg X 60 = 150 mg. and 10 ml of 1% lignocaine contains only 100 mg which is far less than the recommended high dose.  The next drug that was used was Fentanyl 50 micrograms and it is the case of fifth opposite party that initial dose is 50 – 100 micrograms with the loading dose and he relies on the medical literature “Internal Practice of Anesthesia Vol.-I which states as follows: 

Fentanyl is the opioid which has been widely used in combination with local anaesthetics to reliee labour pain.  Clinical experience suggests that fentanyl in an initial does of 50-100 micrograms with 0.125% bupivacaine produces good analgesia, which can be extended with continuous infusion.  The combination of sufentanil-bupivacaine ahs received considerable interest, due to sufentalil’s higher lipid solubility and greater receptor-binding compared with fentanyl.  Epidural injection of 10 ml  0.125% bupivacaine with adrenaline, with either 7.5 or 15 micrograms sufentanil, significantly shortened the onset and increased the duration and intensity of analgesia compared with bupivacaine with adrenaline.  However, there are reports of neonatal depression when doses greater than 30 micrograms have been used.

With respect to Bipuvacaine the amount of drug used by 32.5 mg and the maximum recommended dose is 2 mg per Kg upto 150 mg for the first 4 hrs and 400 mg over the first 24 hours.  (Table 10.4 page no.181 Wylie 6^th Edition. 

This table 10.4 states that the actual does is as follows:

Actual Dose                                               Recommended Dose

          10 ml of Lignociane = 100mg        ----           200 mg without Adrenaline
                                                                             500 mg with Adrenaline

          50 Micrograms of Fentanyl           ----           50-100 Micrograms with
                                                                             loading dose

          32.5 mg of Bipuvacaine in 2 Hrs.   -----                   1)  2mg for Kg. of body weight
                                                                                    upto 150 mg. in 4 Hr.
                                                                             2)    400 mg. in 24 Hours

          32.5 mg. in two hours in far

          Less than recommended dose

          It is pertinent to note that PW2 in his cross examination at page 179 submitted that that the maximum does of Lignocaine that can be given to a pregnant women is 3 mg to 7 mg per kg of body weight and maximum dose of Bupivacine that can be given in epidural analgesia is 2 mg per kg of body weight.  4 ml of 0.125% of bupivacaine is equal to 5 mg of bupivacaine and administration of 5 mg of bupicacaine is not at all a toxic dose.  The last top up does was given at 3.20 A.M.

We find force in the contention of fifth opposite party that the Patient Controlled Epidural Analgesia is a safest and most effective analgesia method and to support his arguments he relied on medical literature of OBSTETRIC ANALGESIA BY A.L.HOLLMEN AND T.A.THOMAS and is as follows:

“ Patient controlled epidural analgesia (PCEA) is an alternative     
     method of epidural analgesian which has recently attracted interest.  Labour pain varies between patients, and over the course of labour and delivery, therefore close titration is needed to achieve effective pain relief with good patient satisfaction, haemodynamic stability and the ability to push effectively during the second stage.  The careful titration of drug has mainly been the responsibility of the anesthetis, and has been costly in staffing levels.  PCEA transfers part of that responsibility to the patient.  Some patients prefer to have the sensation of their contractions and be actively involved in the second stage.  This kind of control of analgesia is difficult to achieve by CIEA.  The preliminary studies suggest that PCEA can be a safe and effective analgesia method offering good patient satisfaction and diminishing personel requirements.”

          We also rely on the requisites of the medical practitioner as described by Halsbury’s Laws of England:

The degree of skill and care required by a medical practitioner is so stated in Halsbury’s Laws of England (Fourth Edition, Vol.30, Para 35):-

“The practitioner must bring to his task a reasonable degree of skill and knowledge, and must exercise a reasonable degree of care.  Neither the very highest nor a very low degree of care and competence, judged in the light of the particular circumstances of each case, is what the law requires and a person is not liable in negligence because someone else of greater skill and knowledge would have prescribed different treatment or operated in a different way; nor is he guilty of negligence if he has acted in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art, even though a body of adverse opinion also existed among medical men. 

          Deviation from normal practice is not necessarily evidence of negligence.  To establish liability on that basts it must be shown (1) that there is a usual and normal practice; (2) that the defendant has not adopted it; and (3) that the course in fact adopted is one no professional man of ordinary skill would have taken had he been acting with ordinary care.” 

Keeping in view the arguments, the material on record and the medical literature filed we are of the considered opinion that the complainants failed to establish that anesthesia was not administered properly and there was no proper monitoring and also that there was drug toxicity. 

The next contention of the complainants is that there was High Block/Total Spinal Block resulting from epidural analgesial.  High Block/Total Spinal Block is the complication of epidural analgesia due to puncture of dura with inadvertent subarachnoid , epidural injection as drug comes in direct contact with spinal cord and cerebrospinal fluid which makes the drug to reach upper spinal cord and brain.  This leads to hypotension, apnea, unconsciousness and bradycardia.   As against this contention fifth opposite party submitted that only after thorough scrubbing and under strict aspectic precautions he administered local anesthesia with 2 ml of 1% Lignocaine at L3 – L4 space in sitting position.  After ensuring analgesia effect 18G Tuohy needle was introduced into L3-L4 space and epidural space was identified by loss of resistance technique using 2 ml of air with glass syringe.  The epidural space was obtained at 5 Cms and after ensuring that there was no fluid or blood, he introduced epidural catheter with the bevel of the needle in caudal direction and fixed at 8 Cms i.e., the catheter was lying only 3 Cms in the epidural space.  He submitted that he aspirated and checked the epidural catheter for any blood or CSF fluid and administered 3 ml of 1.5% Lignocaine via epidural chateter as a test dose.  After waiting for  5 minutes and after confirming that there were no haemodynamic changes, neurological symptoms and motor block he administered 10 ml of 1% lignocaine with 50 micrograms of Fentanyl slowly over a period of 10 minutes.  The patient was kept in  lateral and propped up position and provided oxygen supplementation as routine.  During all this time first complainant and Dr.Rajesh Khanna were present next to the patient and the first complainant was talking to and providing moral support to her.

We observe from the record that the first complainant in his deposition admitted that he was present in the labour room till the patient was shifted in the operation theatre excepting for a brief period of 10 minutes he was giving  moral support and he was talking to the patient on and off.  If there was high spinal or total block there is no chance of patient talking to the first complainant.  Dr.Rajesh Khanna, PW2 stated in his deposition  as follows:

“It is true that the symptom of High Spinal or Total block would appear immediately after accidental injection of analgesic drug into subarachnoid space”

We observe from the case sheet that fifth opposite party gave first dose at 12.30 A.M. and last dose given at 2.30 A.M. and as per the deposition of PW2 if there was a high spinal or total block it ought to have appeared immediately after 2.30 A.M.  Therefore we are of the considered opinion that the complainants failed to establish that because of administration             of analgesia by fifth opposite party there was total spinal or total block and this Spinal Block resulted in death of the patient.

     Now we address ourselves to the contention of the complainants that there was vasovagal shock.

 It is the contention of the complainants that the patient was put in Supine position and she ahs developed severe hypotension and that the deceased was asked to bear down by voluntary efforts, the deceased suffered vasovagal attack which progressed to cardiac arrest.  The learned counsel for the complainant submitted that during epidural analgesia patient should be placed in lateral position with a Wedge to prevent Hypotension but the patient was left in supine position all the while in labour room and even on the stretcher in the operation theatre without placing a wedge, opposite parties continued their treatment.  He relied on the medical literature in International Practice of Anesthesia 1996 Vol-II Page 2/94/2 and 2/96/2 wherein it is mentioned as follows:            

Cavan occulusion occurs when themother is placed in the unmodified supine position and the gravid uterus rests on the inferior vena cava, thus obstructing the return of the blood to the heart……Pregnant mothers at term will not lie supine, but will do so if requested by medical nursing staff. ……Adverse reactions are even more pronounced in the presence of sympathetic block resulting from effective epidural or spinal analgesia.”……”Maternal hypotension is one of the more common complications but the frequency is very loa when aorto-caval compression is avoided 9lateral position throughout labour) and volume loading with lactated Ringer’s solution (10-15ml/kg) is given before block”.        

In Text Book of Anaesthesia, ELBS, 2^nd Edition, Page 546 -547 it is mentioned that Caval occlusion must be avoided at all times and the mother must be nursed in either a lateral position or in modified supine position using a Crawford Wedge.”

In Anaesthiology Clinics of North America, Vol-8, No.1, March 1990 Page 59 it is mentioned that the hemodynamic effects associated with epidural analgesia for labour and delivery may represent a great hazard for mother and baby.  Most of the effects are caused by blockade of the sympathetic fibres.  Sympathetic blockade result in vasodilation of the resistance and capacitance blood vessels.  There is venous pooling and a decrease in venous return to the heart.  The cardiovascular complications of epidural blockade are often preventable.  Aortocaval compresson in the term parturient is the rule and not the exception.  It is the most dangerous vascular feature of the pregnant patient:.

 The learned counsel for  the complainant submitted that RW4 during her cross examination stated that the patient should be kept in the left lateral position with a wedge and that it was done in the present case.  Therefore admitted resuscitation in supine position is futile and that there would be obstruction to venous blood return due to aorta caval compression.  The question whether the wedge was placed or not until sixth opposite party arrived is the brief point for consideration in this contention.  It is pertinent to note from the record that there is absolutely no evidence that the patient was put in a supine position through out and that position was not changed and no wedge was placed.  We find force in the contention of third opposite party that the mother would not at all be comfortable in a supine position  and the mother is always placed in a lateral and not supine position. Moreover it is an admitted fact that the first complainant who himself is a qualified doctor was present in the labour room and talked to his wife to make her comfortable and discomfort,  if any,  with respect to supine position was not complained then at that point of time and there is no documentary evidence to state that the patient was kept in supine position through  out  and that no wedge was placed when the allegations of the complainant is not proved by any documentary evidence we are unable to find any force in their contention. 

Now we address ourselves to the contention of the complainants that third and fourth opposite parties asked the patient to bear down the baby by voluntary efforts.  

The learned counsel for the third opposite party submitted that as the  cervix was not fully dilated at 2-45 a.m.,  the deceased was not asked to bear down.  At 3-30 am as the cervix was dilated to 9-10 cms, the deceased was coached and encouraged to bear down.  Third and fourth opposite parties accelerated the labour with oxytocin and artificial rupture of the membrane.  Ex.A1 is the case sheet states that the cervix was dilated to about 3-4 cms with bulging fore waters and history of draining since 8.00 a.m.  It is the allegation of the complainants that if the membrane was intact,  it is a recommended practice in both induction and augmentation of labour to perform artificial rupture of the membrane.  The learned counsel for the third opposite party submitted that at one instance the complainant says that labour was unnecessarily induced with ARM and on the other hand he says ARM should be done as per recommended practice, ARM was done in view of the indications of active labour and draining since 8.00 a.m.  The learned counsel for third opposite party relied on Role of ARM, Arul Kumaran’s the Management of Labour, Chapter 2 (Volume III, Page 68 wherein it is stated once the active phase has started, i.e., when the cervix is more than 3 cm, the membranes may be ruptured.  This procedure is popular in centers which believe in the active management of labour.   

We rely on the judgment of the Apex Court reported in  I (2002) CPJ 4 (SC) in Vintha Ashok Vs. Lakshmi Hospital and  Others wherein it was been held that when established medical treatments are available  and if the doctor follows one, it cannot be termed as negligence.

Keeping in view that there is absolutely no evidence to state that third opposite party has unnecessarily done ARM, the allegation of the complainant that labour was unnecessary induced is not sustainable.

We now address ourselves to the contention of the complainants that the cesarean was not immediately done to save the lives of the mother and child and also that the death was not caused by AFE. 

It is the opposite parties’ case that due to sudden collapse of the patient after shifting to the theatre, though they resorted to appropriate resuscitation measures, due to non-responsiveness of the mother, and  due to AFE,  the fetal  heartbeat disappeared and even performance of cesarean section would not have served the purpose and therefore in that situation,   cesarean could not be done.  The mother’s condition was grave and the opposite parties admitted that there is no data that any type of intervention would meet maternal prognosis with AFE.  Had it been cardiac arrest and fetal  heart was present then cesarean could have been done.  It is an admitted fact of the opposite parties that fetal  heart disappeared and therefore the contention of the complainants that the performance of the cesarean section  was possible in those  circumstances and was yet not performed by the opposite parties is not sustainable.

We have gone through the medical literature on AFE analsys of the national registry by Steven L.Clark, Internal Page 1160, Vol.III, pageNo.108 to 110 in which it is stated that amniotic fluid embolism is an often-devastating obstetric syndrome occurring in 1 in 8000 to 1 in 80,000 pregnancies.  This condition is responsible for roughly 10% of all maternal deaths and it is most common cause for peripartum death.  The most common clinical features of AFE are collapsing before delivery is a seizure or seizure like activity dyspnea, fetal bradycardia, hypotension and cyanosis.  In William Obstetrics, 21^st Edition, Chapter 25 Obstetrical Hemorrhage, Internal page 660, 661 and 662 Volume No.III, Page 112 and 113 which states that AFE  is a complex disorder classically characterized by the abrupt onset of hypotension, hypoxia and consumptive coagulopathy.  The physiological processes in AFE are still poorly understood, and hence the management of suspected AFE is almost entirely supportive, being derived from basic principles.

We observe that A.P.Medical Council had vide its letter dated 11.2.2004 come to the conclusion that the cause of death of the deceased was due to rare complication of AFE that the entire clinical picture supports the said diagnosis and that there was no negligence on the part of the obstetrician, anesthetist and gynecologist.  Aggrieved by the same the complainant had filed an appeal before Medical Council of India which also ruled that the cause of death was AFE. These reports are however not binding; we address ourselves to the nature of medical negligence only if any, before this Commission.  Even otherwise the medical literature supports the symptoms aforementioned which states that the cause of death was AFE. 

We rely on the judgment of the National Commission reported in Page 52 Vol.II Part A in S.C. and N.C. on Medical Negligence & Insurance under Consumer Protection Act in O.P.No.250 of 1997 dated 24.10.2005 wherein the National Commission has specifically dealt  with AFE.  In this case the deceased was a young patient aged 29 years and labour pains were induced by drugs and she even delivered a male baby and yet died due to AFE.  The National Commission quoted Clarke’s Clinical Presentation on Critical Care Obstetrics    as hereunder.

“ In the typical case of AFE, the woman is laboring vigorously, or has just done so, and is in the process of being delivered when she develops varying degrees of respiratory distress and circulatory collapse.  If the woman does not die immediately, serious hemorrhage with severe coagulation defects is soon evident from the genital tract and all other sites of trauma. 

Treatment:  THERAPY FOR AMNIOTIC FLUID EMBOLISM IS NOTORIOUSLY UNSUCCESSFUL.

The National Commission dismissed the complaint observing that there was no medical negligence of the opposite parties.

The learned counsel for the complainants submitted that the death was not due to AFE but only because of negligence of opposite parties.  The first complainant is a qualified medical doctor and the second complainant is a practicing advocate and they are both aware of the procedures of autopsy and ought to have taken steps to get an autopsy performed if they had any suspicion.   This was not done in the present case the complainants have failed to establish that the cause of death was not AFE.   

In the instant case it is an admitted fact that the cyanosis, seizure and Hypertension were present in the patient and as per the medical literature aforementioned these symptoms are symbolic of AFE and in the absence of any other evidence to prove otherwise we conclude that the cause of death is AFE and we also rely on the judgment of Apex Court in Jacob Mathew, Vs State of Punjab and another reported in AIR 2005 SUPREME COURT 3180 in which the Apex Court dealt with the medical negligence both as Tort and as a crime in a detailed manner and defined ‘Negligence.’ 

According to Charlesworth and Percy on Negligence (Tenth Edition, 2001), in current forensic speech negligence has three meanings.  They are: (i) a state of mind, in which it is opposed to intention; (ii) careless conduct; and (iii) the breach of duty to take care that is imposed by either common or statute law.  All three meanings are applicable in different circumstances but any one of them does not necessarily exclude the other meanings.  (Para 1.01)  The essential components of negligence, as recognized, are three: “duty:, “breach” and “resulting damage”, that is to say:-

1.      The existence of a duty to take care, which is owed by the defendant to the complainant;

2.     The failure to attain that standard of care, prescribed by the law, thereby committing a breach of such duty; and

3.     Damage, which is both causally connected with such breach and recognized by the law, has been suffered by the complainant.  (Para 1.23).

In the instant case the opposite parties have failed to establish that the opposite parties did not take proper care of the patient as per then normal medical standard prescribed by law thereby committing a breach of duty.  From the medical evidenced on record we do not see any recklessness or rashness or any desire to cause harm to the patient.

The Apex Court has stated as follows:

A professional may be held liable for negligence on one of two findings; either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the given case, the skill which he did possess.  The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an  ordinary competent person exercising ordinary skill in that profession.  It is not necessary for every professional to posses the highest level of expertise in that breach which he practices.  In Michael Hyde and Associates V. J.D.Williams and Co.Ltd., (2001) P.N.L.R. 233, CA, Sedley L.J. said that where a profession embraces a range of views as to what is an acceptable standard of conduct, the competence of the defendant is to be judged by the lowest standard that would be regarded as acceptable.  (Charlesworth and Percy, ibid.  Para 8.03)

          In the opinion of Lord Denning, as expressed in Hucks V. Cole, (1968) 118 New LJ 469, a medical practitioner was not to be held liable simply because things went wrong from mischance or misadventure or through an error of judgment in choosing one reasonable course of treatment in preference of another.  A medical practitioner would be liable only where his conduct fell below that of the standards of a reasonably competent practitioner in his field. 

In the instant case except for the allegation of the complainant that the patient died due to negligence of the opposite parties  in administering  anesthesia,  in using strong drugs leading to drug toxicity, not performing  emergency cesarean delivery,  not giving DC shock, non-supply of oxygen to prevent progressive cyanosis and the patient being kept in supine position, their contentions are not supported by any  documentary  evidence wherein the complainants could establish that the opposite parties course of treatment fell below the standard of a reasonable competent practitioner in that field.  To reiterate the first complainant himself is a doctor and the husband of the patient  who was present throughout the procedure and it is also pertinent to note that the opposite parties treated the patient only that crucial night and have acted in accordance with the practice accepted as proper by a responsible body of medical men skilled in that particular act even though a body of adverse opinion also existed among medical men.  A medical practitioner faced with an emergency ordinarily tries his best to redeem patient out of his suffering.   He does not gain anything by acting with negligence or by omitting to do an act.  Obviously, therefore, it will be for the complainant to clearly make out a case of negligence before a medical practitioner is charged with negligence.

We find it relevant here to rely on the decision of the   Apex Court  in Dr.Laxman Balkrishna Joshi v. Dr.Trimbak Bapu Godbole and Anr. (1969) I SCR 206 discussed the duties which a doctor owes to his patients.  The Court held that a person who holds himself out ready to give medical advise and treatment impliedly undertakes that he is possessed of skill and knowledge for that purpose.  Such a person when consulted by a patient owes him certain duties, viz., a duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to be given or a duty of care in the administration of that treatment.  A breach of any of those duties gives a right of action for negligence to the patient. 

In the instant case the complainant did not establish that the opposite parties  have performed any  breach of these duties which gives right of action for  negligence to the patient. 

The Apex Court in INDIAN MEDICAL ASSN. v. V.P.SHANTHA (1995) 6 SCC 651 the court approved a passage from Jackson and Powell on Professional Negligence and held that”

“The approach of the courts is to require that professional

          men should possess a certain minimum degree of competence

          and that they should exercise reasonable care in the discharge

          of their duties.  In general, a professional man owns to his client

          a duty in tort as well as in contract to exercise reasonable care in

          giving advise or performing services”.

Supreme Court then opined as under:

“The skill of medical practitioner differs from doctor to doctor.  The very nature of the profession is such that there may be more than one course of treatment which may be advisable for treating a patient.  Courts would indeed be slow in attributing negligence on the part of a doctor if he has performed his duties to the best of his ability and with due care and caution.  Medical opinion may differ with regard to the course of action to be taken by a doctor treating a patient, but as long as a doctor acts in a manner which is acceptable to the medical profession and the court finds that he has attended on the patient with due care, skill and diligence and if the patient still does not survive or suffers a permanent ailment, it would be difficult to hold the doctor to be guilty of negligence”.

            To sum up,  based on the evidence and  the pleadings put forward and also the medical evidence on record,  we see no negligence on behalf of the opposite parties and this complaint is liable to be dismissed .We also observe that no cause of action can arise  against opposite party No. 4 who expired during the pendency of the complaint.

In the result this complaint is dismissed without costs.

PRESIDENT     LADY MEMBER    MALE MEMBER

                                                                     29.08.2008

*KMK

APPENDIX OF EVIDENCE

WITNESSES EXAMINED

For complainant                                                           for opposite parties

PW1   :  Sri Dr.K.Srikar Reddy          RW1  :  Dr.P.Malathi (O.P.No.3)
PW2   :  Dr.Rajesh Khanna                RW2  :  Dr.M.Padmanabh Reddy (O.Ps.No.1&2)
                                                          RW3  :  Dr.B.Thejeswari (O.P.No.4)
                                                          RW4  :  Dr.L.Sudhakar (O.P.No.5)
                                                                      (O.P.No.6 filed affidavit evidence    
                                                                     and  has not chosen to come to
                                                                     the witness box. Hence his
                                                                     evidence eschewed)

EXHIBITS MARKED

Ex.A1          Case sheet issued by Shalini Maternity Hospital
Ex.A2          Death certificate issued by Dr.B.Thejeswari
Ex.A3          Death Summary issued by Dr.P.Malathi
Ex.A4          Record of ante-natal check ups with Dr.Suvarna Ramaswamy
Ex.A5          Case sheet of Jaya Nursing Home
Ex.A6          SSC Certificate of the deceased
Ex.A7          Intermediate Certificate of the deceased
Ex.A8          Bachelor of Engineering (Electronics and Communications)
                   certificate of the deceased issued by Osmania University
Ex.A9          Diploma Certificate Courtice in Application Development
                   using Java issued by Osdata
Ex.A10        Certificate in Complete Jawa issued by Jawa World
Ex.A11        Certificate in Unix, C, C++, OOPS issued by Frontier Institute
                   of Information Technology
Ex.A12        GRE Report of scores  of the deceased
Ex.A13        TOEFL Examinees score record of the deceased
Ex.A14        Master of Computer and Information Science Certificate
                   of the deceased issued by Cleveland State University, USA
Ex.A15        2000 U.S. Individual Income Tax return Summary of the deceased
Ex.A16        2001 U.S. Individual Income Tax return Statement of the deceased
Ex.A17        Salary Certificate of the deceased
Ex.A18        Compact Discs
Ex.A19        Actual conversation recorded on 10.10.2003 of O.P.No.3
Ex.A20        English Transcription of the Conversation of O.P.No.3 recorded on
                  10.10.03

For Opposite parties

Ex.B1                   Original case sheet issued by Shalini Maternity Hospital
Ex.B2                   Death Certificate of Shalini Hospital sent to MCH
Ex.B3                   Acknowledgement in respect of handing over of copies of
                   documents dated 10.3.2003
Ex.B4                   Acknowledgement dt.11.3.2003 acknowledging receipt of
                   Death Summary
Ex.B5                   Letter dated 13.3.2003 reflecting receipt of death report by the
                   Sub Registrar of Births & Deaths
Ex.B6                   Letter dated 11.4.2003 reflecting acknowledgment of receipt of
                   copies of the case sheet
Ex.B7                   Letter dated 6.5.2003 acknowledging receipt of case sheets
Ex.B8                   Letter dated 24.5.2003 acknowledging receipt of copies of the
                   Case Sheets
Ex.B9                   Letter No.APMC/DC/C.18/2003, dt.11.2.2004 of the Registrar
                   A.P.Medical Council, Hyderabad
Ex.B10        Certificate dated 10.1.1989
Ex.B11        Certificate dated 30.9.1988
Ex.B12        Letter dated 17.6.1994
Ex.B13        Letter of Office Supt. Govt. Maternity Hospital dt.30.12.2003
Ex.B14        Copy of affidavit of Dr.V.S.Rajesh Khanna
Ex.B15        Copy of telephone bill with detailed statement. ( filed by O.P.5)
Ex.B16        Delivery Challan dt.26.1.2001
Ex.B17        Invoice dated 31.12.2004 of Sree Agencies Enterprise to
                   Shalini Hospital
Ex.B18        Quotation dated 21.10.2000
Ex.B19        Technical Information
Ex.B20        Bill dated 24.4.2001 of Agilent Technologies
Ex.B21        Delivery Challan dated 23.4.2001
Ex.B22        Copy of invoice dated 31.1.2001 of JDS Medison India (P) Ltd.,
Ex.B23        Letter dated 25.12.2000 of JDS Medison India (P) Ltd., to
                   Dr.Padmanabh Reddy
Ex.B24        Price Quotation for Convex Desk Top Ultrasound of
                   JDS Medison India (P) Ltd.
Ex.B25        Copy of the insurance policy filed by O.P.No.7

                                      PRESIDENT      LADY MEMBER    MALE MEMBER