SMT. RAVI SUSHA: PRESIDENT
Complainant filed this complaint U/s 12 of Consumer Protection Act 1986 against opposite parties alleging medical negligence on the part of opposite parties Dr. Binu Nambiar OM (OPNo.2) Dr. Veena (OPNo.3) ophthalmologist and the Manager, Vasan Eye care Hospital (OP No.1) in giving treatment to the complainant in relation to cataract surgery of his right eye, claiming Rs,.5,00,000/- as compensation.
Complainant has averred in his complaint that as the complainant was suffering from severe pain and poor vision on his right eye, seeing the advertisement in the media that the institution of the OPs is capable to treat for the ophthalmology related problems, he approached OP No.1 for appropriate treatment. As the complainant was suffering from poor vision coupled with severe pain on his right eye he had sought the treatment from the hospital of OPs initially on 31/07/2013. It is further submitted that OPs No.2 and 3 had prescribed some medicines to the complainant and finally diagnosed the disease of the complainant as “cataract” on his right eye. There after the complainant was advised to undergo for the cataract operation by adopting the procedure by phaceomulsification with foldable IOL implantation. It is further submitted that OPs NO.2 and 3 have conducted the operation for the complainant’s right eye for the diagnosed disease cataract on 28/08/2013 even without complying with pre-operation formalities viz general body check up with the assistance of a General Surgeon/ General Medicine specialist. It is submitted that the suggested operation was conducted on 28/08/2013 and even after the same the complainant was not feeling better, rather his complaints were aggravated and he was suffering from severe pain and poor vision even though the directions of the OPs were complied. It is further submitted that after the treatment for the complainant’s right eye, his vision lost completely and severe pain developed day by day and eventually he was totally collapsed. The complainant being a diabetic patient, he could not withstand further. As the complainant met with such a tragedy he immediately rushed to B K Memorial Hospital, Payyannur on 25/10/2013 and after the careful analysis came to understand that eye sight of the complainant loosing gradually so that they referred him for further treatment to eye specialist one Mrs. Dr. Praveena Unnikrishnan. It is revealed that OPs have misdiagnosed the ailment of the complainant and conducted cataract operation without proper care and caution. The complainant thereafter gone to Aravind Eye Hospital, Coimbatore as per the reference from above said Dr. Praveena Unnikrishnan for further treatment. From Aravind Hospital, Coimbatore, it is learned that the complainant was suffering from secondary open angle Glaucoma and suggested for lens changes. It is submitted that there was gross negligence on the part of the OPs and thereby the complainant sustained loss of eyesight. It is further submitted that the cataract operation conducted by the OPs were on account of their wrong analysis and the same was not done properly. It is also submitted that as matter of fact the wrong diagnosis coupled with wrong prescription the complainant sustained above mentioned injury and financial loss. Therefore the OPs are liable to compensate the same.
It is submitted that there is deficiency in service, negligence as well utmost carelessness in the treatment on the side of the OP. It is submitted that the complainant has issued lawyer notice calling upon the OP to pay the compensation on account of the negligence on their part as stated supra. Though the OPs have received the notice, the same yielded no results. As such field this complaint.
OPs 2 and 3 contested the complaint and denied the allegations of the complainant. Both OPs filed separate versions. But the contentions raised in the versions are more or less same. It was stated that the complainant is not maintainable either in law or on facts. There are no negligence or deficiency in services on the part of the 2nd and 3rd OPs as alleged by the complainant and he is not entitled to get any relief as prayed for in the complaint. It is submitted that the complainant consulted the 2nd OP on 25/07/2013 with complaints of progressive diminishing vision of last one year and mild pain in the right eye. He was a known diabetic patient. The 2nd OP had examined the complainant in detail and he was diagnosed to have grade II nuclear sclerosis type of cataract in both eyes and vision in the right eye was 6/24 and 6/12 in left eye. Intraocular pressure was normal and had no signs of glaucoma. The progressive decrease in vision was not corresponding to the amount of cataract and his fundus examination showed an age related macular degeneration of right eye. The complainant and his wife were informed about the retinal disease caused to the complainant which was the predominant cause for the progressive loss of vision and that should be treated before cataract treatment. For retinal treatment the complainant was referred to the 3rd OP for fundus fluroscience Angiograpy (FFA). There after the complainant was seen and attended by the 3rd OP and fundus fluroscein Angiography was done on 30/07/2013. The FFA showed subfovial neovascular membrane which is a type of age related macular degeneration (WET AMD). Age related macular degeneration is an inherent retinal disease condition with poor prognosis and the outcome of cataract surgery in such patients depends on various predisposing factors related to the retinal disease. The inherent risk were well explained to the complainant and his wife and also given option to go to any other higher centre of their choice. The complainant voluntarily consented for continuation of treatment in the 1st OP Hospital and the 3rd OP in discussion with the patient had advised a line of treatment with three doses of avastine intra vitreal injection. Intra vitereal antibiotic was given under guarded prognosis on left eye with written consent. On 22/08/2013 the 3rd OP had found increasing cataract in RE and given the option for cataract surgery (Phaco) along with 2nd dose of avastin. The patient was referred back to the 2nd OP for cataract surgery. When the complainant consulted the 2nd OP as per reference of the 3rd OP for phaco emulsification and IOL implantation of RE, He was informed that this progressive retinal disease might affect usual recovery of vision after cataract surgery due to factors unrelated to cataract surgery. Hence after fully conversant with the risk factor and prognosis the complainant voluntarily agreed for cataract surgery and he was referred for pre-operative investigations and medical consultation for medical fitness in view of diabetes. The medical officer attached to Taluk Hospital Thrikkaripur examinated the complainant and gave medical fitness after controlling his diabetics. The cataract surgery was scheduled to 28/08/2013 and the complainant underwent all necessary pre-operative evaluation and anesthetic check up and found fit for surgery. He was informed about the guarded prognosis due to inherent disease conditions of retina and risk factors involved in cataract surgery especially since he required intravitreal avastine injection and he and his wife voluntarily gave written informed consent. Under all aseptic care and precautions the 2nd OP conducted phaco emulsification with foldable IOL implantation and following the procedure the 3rd OP had administered intra vitreal avastin injection. The complainant was properly attended in the follow up review and prescribed medicines. On 30/10/2013 the complainant was noted to have developed a corneal oedima with mild rise in intra ocular pressure and the condition was diagnosed as post surgical inflammatory glaucoma which is reported problem in phaco with intravitreal avastin. The complainant was put on anti-glaucoma and anti-inflammatory drugs corneal oedima and intra ocular pressure was noted to have reduced in the follow up visits and he was advised continuation of medicines and follow up. It is seen that in between follow up treatment in the 1st OP hospital, the complainant had also underwent treatment at various other centers including Aravind Eye Hospital for the diagnosed open angle glaucoma caused by increased intra ocular pressure. On 27/10/2013 his post-operative vision was 6/24 with well controlled intra ocular pressure but his macula showed scarring. Though the complainant was advised routine follow up he did not come up and lost further follow up. The complainant was diagnosed to have age related macular degeneration as revealed from fundus fluroscein angiography which is known for progressive loss of vision. There was no negligence or deficiency in service on the part of the 2nd and 3rd OPs and they are not liable to compensate the complainant. It is submitted that the 2nd Open angled glaucoma allegedly diagnosed and treated at Aravind eye Hospital was not caused due to any act or omission on the part of the 2nd OP. In the light of the above mentioned facts the 2nd and 3rd OPs are not liable to compensate the complainant either jointly or severally. Hence prayed for the dismissal of complaint.
Complainant has filed his affidavit and the documents Exts. A1 to A8. On behalf of the OPs, 2nd OP has filed his affidavit for himself and for and on behalf of the 3rd OP also. Produced Exts.B1 medical Record of OP No.1’s hospital pertaining to the treatment of the complainant, Ext.B2 Angiogram report. From OP side one witness Dr. Dolly Francis (ophthalmologist) who was one of the member who prepared medical Report, Ext.X1 was examined as Dw2. All witnesses were subjected to cross-examination by the rival parties.
After that the learned counsel of complainant and the learned counsel of OPs vehemently argued the matter. From the side of OPs, filed written arguments note, judgments of Apex court and medical literature for reference.
In this case the medical negligence and deficiency in service put forth by the complainant is in regard to the complainant having contacted with severe pain and poor vision on his right eye, resulted loss of eye sight of right eye is attributed to the wrong diagnosis coupled with wrong prescription adopted by OPs 1 and 2 in conducting cataract surgery without proper care and caution and without pre-surgical procedure of adopting International test and General check-up.
The next allegation is even after the operation, he felt severe pain and poor vision in his operated eye despite he complied the directions of the OPs and informed to the OPs about the complaint, but OPs did not give any care. Another allegation is that after the treatment of OPs for the complainant’s right eye, his vision lost completely and servere pain developed day by day. Since complainant being a diabetic patient, he could not withstand further. Hence he went for further treatment.
We have perused the evidence available before us and have considered the submissions of both learned counsels. It is not disputed that after surgical procedure of phaco emulsification with foldable IOL implantation by OP No.2 after retinal treatment of fundus fluroscience Angiograph (FFA) by OP NO.3 and given 3 doses of Avastin intra vitreal injection, the complainant diagnosed secondary open gluncoma on his right eye at Aravind Eye hospital. Therefore the question to be decided in this case is whether the said diagnosed disease at Aravind Eye Hospital was result of any act of omission and commission as alleged by the complainant on the part of the OPs which can amount to negligence or deficiency in service.
The question as to when a medical professional can be held guilty of medical negligence has been considered by the Hon’ble Supreme court in several of the decisions. While deciding question whether medical Professional is guilty of negligence the matter to be considered are (A) Negligence is the breach of a duty exercised by omission to do something which a reasonal man, guided by those considerations which ordinarily regulate the conduct of human affairs, would do or doing something which a prudent and reasonable man would not do (B) The medical professional is expected to bring a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. (C) A Medical practitioner would be liable only where his conduct fell below that of the standards of a reasonably competent practitioner in his filed. (D) In the area of diagnosis and treatment there is scope for genuine difference of opinion and one professional doctor is clearly not negligence merely because his conclusion differs from that of other professional doctor.
In the present case there is no allegation that the OP Nos.2 and 3 were not aqualified and experienced ophthalmologist for conducting the Ophthalmology treatment. The fact that complainant had approached OP No.2 shows that complainant must have satisfied himself about the skill, experience and repulation of OP No.2 as a competent Ophthalmologist.
Here complainant’s allegation is that OPs 2nd and 3 have conducted the operation for the complainants right eye for the diagnosised disease cataract on 28/08/2013 even without complying with pre-operation formalities ie general body check up with the assistance of a General surgeon. Further alleged that OPs have misdiagnosed the ailment of the complainant and conducted cataract surgery without proper care and caution and further alleged that actually complainant was suffering from secondary open angle glaucoma and there was gross negligence on the part of OPs by conducting cataract operation on account of their wrong analysis and thereby complainant sustained loss of right eye sight.
According to OPs complainant consulted OP No.1 on 25/07/2013 with complaint of progressive diminishing vision for last one year and sever pain in the right eye. He was a known diabetic patent. He was diagnosed to have grade II nuclear sclerosis type of cataract in both eyes and vision in right eye was 6/24 and 6/12 in left eye. The progressive decrease in vision was not corresponding to the amount of cataract and his fundus examination showed an age related macular degeneration (ARMD) of right eye. Thus according to OP No.2 fundus examination showed he had retinal disease which was the predominant cause for the progressive loss of vision and that should be treated before cataract treatment. So OP No.2 had referred the patient to OP No.3 for Fundus Fluro Science Angiography (FFA) and OP No.3 had done FFA on the patient on 30/07/2013, which showed subfovial neovascular membrane which is a type of age related Macular Degeneration (WET AMD). OPs submitted that WET AMD is an inherent retinal disease condition and the outcome of cataract surgery depends on various predisposing factors related to the retinal disease. It is further submitted that the inherent risk factors were well explained to the complainant and the complainant voluntarily consented for continuation of treatment in this OP No.1 hospital and thus OP No.3 had continued the treatment and advised a line of treatment with three doses of avastin vitreal injection. It is also contended that after 1st dose of Avastin injertion OP No.3 had found increasing cataract in right eye and given the option for cataract surgery along with second dose of avastin and the patient was referred back to OPNo.1 for cataract surgery. It is further submitted that after fully conversant with risk factors and prognosis, the complainant voluntarily agreed for cataract surgery and he was referred for pre-operative investigations and medical consultation for medical fitness in view of diabetes. The medical officer attached to Taluk Hospital, Thrikkaripur examined the complainant and gave medical fitness after controlling his diabetes. According to OP No.2, he had conducted phacoemulcification with foldable IOL implantation with all aseptic care and precautions and following the procedure the third OP had administered intra vitreal Avastin Injection. Further stated that the complainant was properly attended in the follow up review and prescribed medicines. It is submitted that on 03/10/2013 the complainant was noted to have developed corneal oedema with mild rise in intraocular pressure and the condition was diagnosed as post surgical inflammatory glaucoma, which is reported problem in phaco followed by Avastin. Then the patient was put on Anit-glaucoma and anti-inflammatory drugs and the corneal oedema and intra ocular pressure was noted to have reduced in the follow up visits and he was advised continuation of medicines and follow up.
It is also submitted that in between follow of treatment in the 1st OP hospital, the complainant had also underwent treatment at various other centers including Aravind Eye Hospital for the diagnosed open angle glaucoma caused by increased intra ocular pressure. Further on 27/10/2013 his post operative vision was 6/24 with well controlled intra ocular pressure but his macula showed scarring. Further though the complainant was advised routine follow-up, he did not come up and lost further follow up.
From the side of OPs produced Text book Peyman’s principles and practice of ophthalmology pertaining to Age related Macular degeneration, it is mentioned in page 844 that “Age related macular degeneration is slowly progressive degenerative disease with pathology centered principally macula Iutea it accounts for approximately 9% of all global blindness. AMD is the leading cause of blindness in developed countries. In the United States of America, it was estimated in 2004 to account for 54% of blindness and 23% low vision in Caucasian people. However in advanced cases, AMD leads to severely reduced central vision and loss of visual acuity, often in both eyes. For this reason, AMD has major implications for individuals and for society, as patients with this condition may experience many years of decreased quality of life, reduced independence, and even depression. Early AMD is characterized clinically by the presence of macular drusen in individuals aged 50 years and above.
In page 848 again the literature as under the head Late, it is important to note that these can coexist in the same eye; atrophic lesions may develop neovascular disease and neovascular disease is frequently followed by outer retinal atrophy. Neovascular AMD is characterized by the growth of new blood vessels from the choroid into the subretinal or sub-RPE space, in the form of choroidal neovascularization (CNV).
Age related macular degeneration is explained in the book Peyman’s Principles and practice of Ophthalmology stated that
- Age related macular degeneration is slowly progressive degenerative disease with pathology centered principally macula lutea it accounts for approximately 9% of all global blindness. Md is the leading cause blindness in developed countries.
- Late age related macular degeneration explained is that it is important to note that these can coexist in the same eye; atrophic lesions may develop neovascular disease and neovascular disease is frequently followed by outer retinal atrophy.
- Neo Vascular age related macular degeneration explained that Neovascular AMD is characterized by the growth of new blood vessels from the choroid into the subretinal or sub-RPE space, in the form of choroidal neovascularization (CNV).
- Fundus Flurescein-angiography shown in page 850
- Risk factors for age related macular degeneration is that in addition to increased age, susceptibility to AMD can be considered through a combination of genetic and environmental factors
- Increased age associated with increased age of AMD increases exponentially with age.
- Genetic risk factors age related macular degeneration is in page 853
- In the text book Parson’s disease of eye is that ARMD is one of the leading causes of blindness in the world and presents as two forms: ‘dry’ or atrophic and ‘wet’. Macular degeneration is more common in people older than 65 years. The exact causes of ARMD are still unknown.
From the above, it is clear that when the patient had ARMD, it is not possible to get his full eye vision back after cataract surgery.
One of the allegations raised by the complainant that OPs 2 and 3 had conducted the operation for the complaint’s right eye for cataract even without complying with pre-operation formalities ie General body check up with the assistance of a General Surgeon or General Medicine specialist.
On the other hand OP submitted that before the cataract surgery, the patient was directed to Medical officer attached to Taluk Hospital Trikkaripur for medical fitness and the medical officer after examining the patient gave medical fitness after controlling his diabetic.
On perusal of Ext.B1 Medical Record in page 15 it is seen that OP No.2 had obtained Fitness Certificate for cataract surgery from Medical officer, Taluk Hospital, Thrikkaripur. So the allegation of complainant with Regard to said point is not sustainable. Further Ext.B1 clearly shows that in each surgery and even for doing FFA and for giving Avastin injection, OP No.3 had obtained consent statement of complainant and his wife.
Another allegation of complainant is that Dr. Praveena Unnikrishan opinioned that OPs have misdiagnosed the ailment of the complainant and conducted cataract operation without proper care and caution. Ext.A5 and Ext.A6 are the discharge summary Report of Aravind Eye hospital. On perusal Ext A5 dated 30/09/2013 it t is written that Diagnosis RE-Secondary open Glaucoma, and type of surgery is AC paracentesis Right Eye. In Ext.A6 dated 14/10/2013. Type of surgery was Trabeculactomy with mytomycin. The complainant could have examined Dr.Praveena Unnikrishnan to prove the allegation that OPs have misdiagnosed the ailment of the complainant and conducted cataract operation without proper care and caution. Ext.B1 shows that on 31/07/2013 the diagnosis of OPs was RE –SUBFOVEAL CNVM means due to means ie ARMD age related macular degeneration and procedure :-RE –Avastin. Further shows that on 28/08/2013 the Diagnosis as cataract Right Eye and procedure done was phacoemulsification with foldable IOL implantation under Topical Anesthesia + Avastin.
In the present case the complainant alleged that there was gross negligence on the part of the OPs and thereby the complainant sustained loss of eye sight. It is be noted in Ext.X1 the Medical Board Report, of District Hospital, Kannur constituted on 24/05/2017 reveals that the complainant was examined and found that optic disc pallar RE due to secondary Glaucoma RE. Macula shows ARMD and choreo retinal scar, Left eye shows ARMD and opinioned that the complainant has 40 % visual disability. Further one of the Member in the Medical Board Dr. Dolly Francis was examined as Dw2 from the side of OP. On analysis of Dw2’s evidence revealed that ARMD 2 കണ്ണിലുള്ളതായി രേഖപ്പെടുത്തിയിട്ടുണ്ട്.Further stated that റെറ്റിനയിൽ ARMD പോലുള്ള അസുഖങ്ങൾ ഉണ്ടാകുകയാണെങ്കിൽ തിമിര ശാസ്ത്രക്രീയയാ ചെയ്താൽ കാഴ്ച ശക്തി തിരിച്ചുകിട്ടണമെന്നില്ല. During cross examination, the learned counsel of complainant put a question that രോഗിക്ക് secondary glaucoma ആയ കേസുകളിൽ തിമിരശസ്ത്രക്രീയ എല്ലാ കേസുകളിലും advisable ആണോ? Severe wet ARMD ആണെങ്കിൽ അതിന്റെ ചികിത്സനടത്തിയതിനു ശേഷമാണ് തിമിര ശസ്ത്രക്രീയ ചെയ്യുന്നത്. Ext.B1 നോക്കിയാൽ wet ARMD ആണോ എന്ന് കാണുമോ? (A) കാണും. wet ARMD ആണ്. അതുകൊണ്ടാണ് Avastin injection \നൽകിയത്. Avastin injection നൽകിയതിന് ശേഷമേ ശസ്ത്രക്രിയ നടത്താൻ പറ്റൂ.
In the present case, the evidence of Dw2 can be treated as an expert opinion. On the strength of the above Medical opinions, the learned counsel for OPs argued that on the first examination of the complainant, the OP found that his right eye had certain disorders and diagnosed that age related macular degeneration (ARMD) of right eye. For further evaluation FFA test was also conducted and confirmed that he had ARMD. Avastin injection was given to cure and control ARMD and it is proper treatment for the said disease and since getting of the full eye vision is not possible that the retinal disorder was due to ARMD, we cannot say that any act of commission or ommission on the part of the OPs 2 and 3. The above said contention cannot be refused in the absence of any cogent evidence having been brought on record to show that the poor vision as alleged was suffered by the complainant was due to medical negligence ie wrong diagnosis coupled with wrong prescription. Hence the injury and financial loss as alleged caused to the complainant must not be on account of negligence of OPs. On the other hand the condition as alleged by the complainant must be due to age related.
One of the submission made by the learned counsel of complainant during the argument time that OP No.2 Dr. Veena is purposely evaded from appearing before the commission in giving evidence. According to the Learned counsel that itself shows that the FFA done by her and after diagnosed RE Diabetic macular edema and further giving avastine 3 doses to the patient are not proper procedure adopted by her. Here it is seen that OPNO.2 have given evidence for himself and for and on behalf of OP No.3 also. Moreover DW2 the expert opinioned the procedure adopted by OP No.3 ie advised to do FFA and after diagnosed the condition of the RE of the patient and giving Avastin are proper mode of treatment in case of complainant on Medical science. We can see that OPs 2 and 3 had not suggested cataract surgery on the patient on the 1st day of consultation itself. On 01/08/2013 OP No.3 diagnosed RE-SubFoveal CNUM ie ARMD on the RE of patient and adopted the procedure RE AVASTin intra vitreal injection. According to OPs the treatment started on the patient only after obtained informed consent form the patient and his wife, each and every treatment started on the patient, after obtained informed consent which can be seen in Ext.B1 case record also. Further OP NO.3 contended that after giving 1st dose of Avadstin intra Vitreal injection as she found increasing cataract in RE, given the option for cataract surgery along with second dose of Avastin and referred the patient to OP No.2. Further 2nd
OP after obtaining voluntary informed consent for cataract surgery, referred the patient for pre-operative investigations and medical consultation for medical fitness in view of diabetes from the Medical officer attached to Taluk Hospital Trikaripur, seen in Ext.B1 and after obtaining Medical fitness, done the cataract surgery on the patient and given 2nd dose, Avastin injection. This way of treatment adopted by OPs 2 and 3 and suggestion of doing cataract surgery on the patient is also admitted by DW2 as proper way of treatment.
In this situation the Judgment of Hon’ble Apex court submitted by the Learned counsel of OP that in Harish Kumar Khurana 2021 10 SCC291) Followed in Chanda Rani VS. Methusethupathy 2022 osup(Sc) 335, Hon’ble State Commission held that in every case where the treatment is not successful, it cannot be automatically assumed that the medical professional was negligent. To indicate negligence there should be material available on record or else appropriate medical evidence should be tendered. Further in DR.Moly John Vs. Lucky Johny (20013(3) CPR 60)the Hon’ble Kerala State Commission held that what is expected from a doctor is not the standard of treatment which is the highest to or lowest but of reasonable standards.
In Another case in Jacob Mathew case ((2005) 6 SCC 1) the onus to prove medical negligence lies largely on the claimant and that this onus can be discharged by leading cogent evidence. A mere averment in a complaint which is denied by the other side can by no stretch of imagination, be said to be evidence by which the case of the complainant can be said to be proved.
Learned counsel of OP further submitted that Text books Peyman’s principles and practice of ophthalmology for reference.
In the instant case except the Discharge summary from the Aravind Eye Hospital and from BKM Memorial Hospital Payyannur, no other medical evidence medical literature or Medical opinion has been submitted. The Hon’ble State Commission held that onus to prove Medical negligence lies upon the complainant. Moreover Dw2 the expert sited from the side of OP, opinioned that the way of treatment adopted OPs 2 and 3 were in proper. Further Ext.B1 shows pre-surgical opinion was obtained by OPs from a Medical officers. Then complainant should have proved that after the cataract surgery the complaints of his right Eye aggravated and he was suffering from severe pain and poor vision and which was caused to him due to wrong diagnosis coupled with wrong prescription adopted by OPs, which amounts to Medical negligence on their part.
Thus on a consideration of the submissions put forth on behalf of the parties and in view of the laws laid down by the Apex court on the subject and also from Medical literature available before us, we are of the considered opinion that the complainant has not been able to establish any medical negligence or deficiency in service on the part of the opposite parties.
In the result, the complainant fails and hence it is dismissed. No order as to cost of the proceedings.
Exts.
A1-Discharge summary dated 31/07/2013
A2-Discharge summary dated 28/08/2013
A3-Discharge summary(BKM Hospital) dated 28/09/2013
A4-Prescription dated 27/09/2013
A4-Discharge summary(Aravind Hospital) dated 07/10/2013
A6-Discharge summary dated 18/10/2013
A7-Notice dated 24/12/2013
A8-Reply notice dated 10/01/2014
X1-Medical board Report
B1-Case sheet of Vasan eye care
B2-Angiogram Report (Subject to proof)
Pw1-Complainant
Dw1-OP No.2
Dw2-Dr.Dolly Francis-Witness of OP
Sd/ Sd/ Sd/
PRESIDENT MEMBER MEMBER
Ravi Susha Molykutty Mathew Sajeesh K.P
(mnp)
/Forward by order/
Assistant Registrar
