Andhra Pradesh

East Godwari-II at Rajahmundry

cc/10/2013

Esukapatla Suni Satyam Sundar Satya Keerthi Raju - Complainant(s)

Versus

The Managing Director, Raju Emergency Hospital - Opp.Party(s)

K. Suneel Lionel

15 Mar 2016

ORDER

                                                                                      Date of filing:   28.03.2013

                                                                                                Date of Order: 15.03.2016

 

BEFORE THE DISTRICT CONSUMER FORUM-II, EAST GODAVARI

DISTRICT AT RAJAHMUNDRY

 

                           PRESENT:   Smt H.V. Ramana, B.Com., L.L.M.,   PRESIDENT(FAC)

                      Sri A. Madhusudana Rao, M.Com., B.L., MEMBER          

    

                 Tuesday, the 15^th day of March, 2016

 

C.C.No.10 /2013

Between:-

 

Esukapatla Suni Syam Sundar Satya Keerthi Raju,

S/o. Late Immanuel, aged 46 years, Advocate,

D.No.90-2-1, Swarajyanagar, Alcot Gardens,

Rajahmundry – 533 101.                                                                    …        Complainant

 

                                    And

 

The Managing Director,

Raju Emergency Hospital, Raju Multispecialty Hospital,

Raju Neuro Hospital (a division of Raju Neuro &

Multispecialty Hospitals (P) Ltd., D.No.76-4-7,

Opp. Doctors Diagnose Centre, Gandhipuram-2,

Rajahmundry – 533 103.                                                                   …        Opposite party

 

            This case coming on 02.03.2016 for final hearing before this Forum in the presence of Sri K. Suneel Lionel, Advocate for the complainant and Sri Ch. Prabhakar Rao, Advocate for the opposite party, and having stood over till this date for consideration, this Forum has pronounced the following:  

 

O R D E R

[Per Smt.H.V. Ramana, President(FAC)] 

This is a complaint filed by the complainant U/Sec.12 of Consumer Protection Act 1986 to direct the opposite party to pay the bill amount that was collected illegally from the complainant without proper treatment i.e. Rs.59,950/-;   pay Rs.1,77,117/-, the additional bill incurred by the complainant in view of the negligence on the part of the opposite party; pay Rs.3,00,000/- towards damages for deficiency of services and negligence; pay Rs.2,00,000/- towards damages for loss of income of the complainant; award subsequent interest at 24% p.a. and award costs of the complaint.

2.         The case of the complainant is that on 28.6.2011, he met with an accident and admitted in Sai Hospital, Rajahmundry on the examination and tests conducted by the doctors, they came to know that the complainant sustained fractured injuries on both on femur bones and some damage on his spinal card. Thereafter, the complainant was shifted to the opposite party hospital on 29.6.2011, where Dr. Pardhasaradhi treated to his both legs. The opposite party hospital unnecessarily conducted many tests only to extract money every day two times, the opposite party hospital conducted ABG test, each test cost Rs.650/-. Finally, on the advice of the well-wishers, the complainant was shifted to NIMS, Hyderabad on 7.7.2011. At the time of discharge, the staff and Directors of the opposite party hospital created most unhealthy atmosphere.  In view of the negligence on the part of the opposite party, the complainant incurred an additional amount of Rs.1,77,117/-.  On 19.01.2012, the complainant got issued a legal notice to the opposite party hospital; the opposite party got it returned the notice with false endorsement. Hence, the complaint. 

3.         The opposite party filed its written version and denied all the allegations made by the complainant and the complaint is not maintainable either under law.  The above complaint is not maintainable for non-joiner of necessary parties. As per reading of the complaint, the complainant has grievance against Dr. Partha Sarathi, who is not a party to the complaint. Hence, the complaint is liable to be dismissed for non-joinder of necessary parties.  The opposite party’s hospital is an emergency hospital having various facilities to cater the needs of the needy patients requiring emergent medical assistance. Dr. Partha Sarathi is an orthopedic surgeon having his independent clinic which is unconnected with the opposite party’s hospital. However, Dr. Partha Sarathi used to avail the opposite party’s hospital for his patients for rendering multi specialty services depending on the nature of condition of the patient. In such context, Dr. Partha Sarathi got the complainant admitted into the opposite party’s hospital on 29.6.2011. Since Dr. Partha Sarathi was the doctor in-charge of the patient, the opposite party is only supposed to extend its multi specialty services to the patient under the guidance and instructions of Dr. Partha Sarathi. Accordingly, Dr. Partha Sarathi after having admitted the patient for such multi specialty services from the opposite party’s hospital, continued to treat the patient. As a matter of fact, Dr. Partha Sarathi was not only treating the patient regularly but also applied pin-traction to the patient on 2.7.2011 to relieve the pain and to prevent shortening till the time the patient becomes fit for surgery. As per the instructions, the other medical parameters of the patient were being attended to by the opposite party’s hospital without any negligence or dereliction of duties. The opposite party’s hospital never prescribed medicines unnecessarily as alleged.  This opposite party’s hospital never conducted any test unnecessarily. Only relevant medical tests were prescribed to the patient more particularly at the instance of Dr. Partha Sarathi and medication was also prescribed to the complainant in the same manner. The patient was admitted into the opposite party’s hospital with multiple fractures and injuries and in a critical condition. Dr. Partha Sarathi opined that the patient requires major surgery. However, the oxygen levels etc. of the patient were not to the optimum level for becoming fit to undergo surgery. In order to find the percentage of minimum oxygen level in blood, constant monitoring is required by way of ABG test and accordingly such tests were being done from time to time as per the instructions of Dr. Partha Sarathi, chest physician Dr. Ram Mohan and critical care specialist Dr. Krishna Prasad. The oxygen levels of the patient were far below normal range at all times when he was an inpatient in the opposite party’s hospital despite the constant efforts made by the opposite party. Therefore, there is no intentional delay in keeping the patient without conducting surgery. In any view of the matter, it is for the concerned Dr. Partha Sarathi to take a decision in consultation with the said team of doctors to find out whether the patient is fit for surgery or not?  Therefore, the allegations made contra to the above are all false and incorrect. During admission into the hospital, the opposite party was found to have sustained the following injuries: (1) Wadge compression fracture of D12 – Vertebral Body,                 (2) Fracture to both femurs, (3) Right temporal small hemorrhagic contusion and                     (4) Fatembolism or Pulmonarythromboembolism.  The patient was having low blood pressure by the time of his admission and it was stabilized by the opposite party’s hospital by giving him necessary treatment and monitored the blood pressure levels by adjusting the drugs accordingly. Dr. R.V. Ravi, neuro surgeon also visiting the patient periodically to monitor the injuries sustained to brain and spine of the complainant. Dr. Ram Mohan, chest physician was also visiting the complainant to monitor the low oxygen content in the blood of the complainant. Dr. Krishna Prasad, critical care specialist was also monitoring the case. It is false to state that the opposite party’s hospital was reluctant to discharge the complainant from the hospital. All such allegations are made for the purpose of present complaint. The opposite party’s hospital was also endorsing the view of the attendants and well-wishers of the patient to shift him to higher center in view of the condition of the patient. As a matter of fact, the opposite party’s hospital extended the services of Dr. Ram Bhoopal Reddy, who was made to travel along with the patient in the Ambulance up to NIMS, Hyderabad. This opposite party’s hospital  took only a nominal advance from the complainant and also billed the complainant nominally. However, at the time of discharge of the complainant, the attendants of the complainant intentionally raised dispute with the opposite party’s hospital to avoid payment of bill while being discharged.  The present complaint is only an outcome of such an attempt and to gain wrongfully at the expense of the opposite party’s hospital. This opposite party never received any legal notice from the complainant. Hence, there is no negligence or deficiency in service on the part of the opposite party’s hospital and the complaint is liable to be dismissed with costs.  

4.         The chief affidavit filed by the complainant and Exs.A1 to A9 have been marked on behalf of P.W.1 and Exs.A10 to A19 on behalf of P.W.2 and also marked Ex.X1 medical record of NIMS Hospital, Hyderabad. The proof affidavit filed by the opposite party and Ex.B1 has been marked.  

5.         Heard both sides. Written arguments filed on behalf of the complainant.

6.         Points raised for consideration are:

 

1. Whether there is any deficiency in service on the part of the opposite party?

            2. Whether the complainant is entitled for the reliefs asked for?

            3. To what relief?

 

 

7.  POINT Nos.1 & 2:   The admitted facts are that the complainant met with an accident on 28.6.2011 and admitted in Sai Hospital, Rajahmundry and on examination and tests were conducted by the doctors and came to know that the complainant sustained multiple fractures to both the legs and some damage on the spinal card. The complainant was shifted on the advice of Dr. R. Partha Sarathi to the opposite party hospital on 29.6.2011 vide Ex.A1.        Dr. Partha Sarathi laid traction on his legs and stated that the complainant is normal and he will conduct treatment on 30.6.2011, but he never visited the complainant later. The complainant contended that the opposite party never disclosed anything about the diagnosis to their family members, but they always craved for money, but not for the treatment of the complainant. The complainant also contended that they conducted many tests and prescribed unnecessary medicines due to negligent treatment of the opposite party, the complainant had infection in and around his wounds and fractures. The complainant also contended that the opposite party did ABG tests unnecessarily and collected money from him. Due to the negligent treatment of the opposite party to the complainant, they are liable to pay damages and liable to pay hospital bill and also amount spent for further treatment.  The complainant submitted on the advice of his friends and well wishers, he was shifted to NIMS, Hyderabad for further treatment. He also contended that the opposite party hospital was reluctant to discharge him and created unhealthy atmosphere and caused mental agony to his family members for extracting money. The opposite party gave unnecessary treatment which amounts to deficiency in service. The complainant filed the discharge summary issued by the opposite party vide Ex.A2 and also the amount collected from him i.e. cash bill vide Ex.A3. The complainant also filed the prescriptions and receipts issued by the opposite party vide Exs.A7, A8 and A9. The complainant was admitted in NIMS Hospital, there they issued medical certificates vide Ex.A10 and A11. After taking the treatment from Nizam Institute of Medical Sciences, they issued discharge summary of the complainant vide Ex.A12 and also issued Essentiality certificates vide Ex.A13 and A14. The report given by Pathology Department marked as Ex.A15. C.T Scan request form marked as Ex.A16 and Lung Perfusion Scintigraphy report marked as Ex.A17. Echo Cardiogram conducted on 12.7.2011 marked as Ex.A18.  The medical bills issued by the NIMS Hospital marked as Ex.A19. After discharged from NIMS Hospital, he has taken further treatment in Chakardhar Hospital vide Ex.A4. The complainant contended that he had incurred lot of expenditure due to the negligent treatment of the opposite party and got issued a legal notice to the opposite party vide Ex.A5, but the same was returned with an endorsement that the opposite party was absent vide Ex.A6.   

            This Forum summoned the medical record of the complainant from NIMS and the same is marked as Ex.X1.

            The opposite party filed its written version and denied the allegations made by the complainant. This opposite party contended that this complaint is not maintainable for non-joinder of necessary parties. As per the complaint, the complainant has grievance against Dr. Partha Sarathi, who is not a party to this complaint. Hence, the complaint is liable to be dismissed for non-joinder of the parties. This opposite party hospital is an emergency hospital having various facilities to fulfill the needs of the needy patients requiring emergent medical assistance. Dr. Partha Sarathi is an orthopedic surgeon having his independent clinic, which is unconnected with the opposite party’s hospital.  Dr. Partha Sarathi used to avail the opposite party hospital for his patients for rendering multi specialty services depending upon the nature of the patients. In that context, Dr. Partha Sarathi got the complainant admitted in the opposite party’s hospital on 29.6.2011. Since Dr. Partha Sarathi was the doctor in-charge of the patient, the opposite party is only supposed to extend its multi specialty services to the patient. Dr. Partha Sarathi after admitting the complainant in the opposite party hospital, he continued to treat the complainant regularly. As a matter of fact, Dr. Partha Sarathi was not only treating the patient regularly, but also applied pin-traction to the patient on 2.7.2011 to relieve the pain and to prevent shortening till the time, the complainant becomes fit for surgery. The complainant vaguely made several allegations against this opposite party and this opposite party never conducted any unnecessary tests or prescribed any medicines. The relevant medicines prescribed by Dr. Partha Sarathi only administered to the complainant. At the time of admission of complainant in the opposite party hospital, he had multiple fractures and injuries and he was in a critical condition. Dr. Partha Sarathi opined that the patient requires major surgery. But the oxygen levels etc. of the patient were not to the optimum level for becoming fit to undergo the surgery.  In order to find the percentage of minimum oxygen level in the blood, constant monitory is required by way of ABG test and accordingly such tests were being done from time to time as per the instructions of Dr. Partha Sarathi, Chest Physician, Dr. Ram Mohan and Critical Care Specialist Dr. Krishna Prasad.  The said reports are herewith filed vide Ex.B1. The opposite party also contended that the oxygen levels of the complainant were fall below normal range and the platelet count was also below the range. The opposite party made several efforts to bring the levels to the normal range in order to make him fit for the surgery. There is no intention to delay the surgery to the complainant. 

                At the time of joining the complainant in his hospital, he found that the complainant sustained the following injuries:

(1) Wedge compression fracture of D12 – Vertebral Body,

(2) Fracture to both femurs,

(3) Right temporal small hemorrhagic contusion and

(4) Fatembolism or Pulmonary-thrombo embolism.

At the time of admission, the complainant had low blood pressure and the same was stabilized by giving necessary treatment and monitored the blood pressure by giving him necessary drugs accordingly.  Dr. R.V. Ravi, Neuro Surgeon also visited the complainant periodically to monitor the injuries sustained to brain and spine of the complainant. This hospital while referring the patient to NIMS extended their services by sending Dr. Ram Bhoopal Reddy along with the complainant in the Ambulance up to NIMS, Hyderabad. Therefore, there is no deficiency in service on the part of this opposite party and the complaint is liable to be dismissed.

            The complainant was examined as P.W.1 in which he stated that on the advice of the well wishers, he was shifted to the opposite party’s nursing home and he also stated that he himself or his family members never consulted Dr. Partha Sarathi before joining to the opposite party’s hospital. He also stated in his complaint that on the advice of Dr. Partha Sarathi, he was joined in the opposite party’s hospital.  He also submitted that by the date of his accident, Dr. Partha Sarathi is not having a good nursing home. He further stated that his wife was attending him and consulting the doctors and informed him about the necessity of surgery for both the legs. He also admitted that ABG test is required to know the oxygen level in the blood. He was also stated that he was informed by the doctors that the platelet count is far less than the normal blood count and they are treating for improvement of the same.

            Dr. Raju Iyangar, who is an Orthopedic doctor of NIMS Hospital, Hyderabad also examined as P.W.2, in which he stated that the complainant was treated for one week in the local hospital and shifted to NIMS for further management. At the time of admission of the complainant, he was conscious and coherent, vital stable with decreased oxygen saturation. After taking the opinion of anesthetist, there was low saturation and repeated ABGS, Po-2 was very varying from 58 to 90, this was probably because of pulmonary thrombo embolism on the background of chronic obstructive airway diseases. The anesthetist opined to continue on face mask till ABG’s value returned to normal and also advised to keep stabling ABG’s on face mask and room air, so that the patient can taken for surgery. Even on the above said levels are remains same. On 14.7.2011, the ABG’s value slightly improved. Again, the respiratory care unit proqussials consultant and posed for surgery and in the meanwhile lung perfusion Scintigraphy was done to rule out pulmonary thrombo embolism and the outcome is negative. Then the complainant was operated right side leg nailing on 15.7.2011 and the left side surgery was postponed because of taking partial pressure of oxygen in blood. The left side surgery was completed on 20.7.2011. The complainant was discharged on 29.7.2011 and get readmitted for one more surgery i.e. spine fixation. The said surgery is required under general anesthesia. In his cross examination, he stated that they have stabilized the complainant before surgery to make him fit for the same from the date of admission i.e. 15.7.2011. He also stated that minimum saturations for undergoing anesthesia and surgery is 100 per cent and PAO-2 means partial pressure of oxygen in blood which is one of the important parameters we consider before surgery. It should be at least 80% for considering surgery.  He further submitted that if required ABG test will be conducted many times in a day. The main issue in ABG is clearly output of normality like ventilator face mask, non invasion ventilation on room air. He also stated that the complainant is a smoker before injury, therefore, he was having airway disease may be due to smoking. This chronic pulmonary disease might cause delay in improvement of pressure of oxygen in blood. The platelet count is also one of the parameter to be considered before surgery. In this case, two long bones of the complainant were fractured and there is a chance of fat embolism is high. The fractures of this nature, before the patient is stabilized for surgery pin traction could be applied. To immobilize the fracture bones as any such movement may increase fat embolism.

            After going through the material on record and evidence of the P.Ws.1 & 2, it is clearly showing that in Ex.B1, one of the report dt.30.6.2011 showing that the platelet count of the complainant is 120000 which is below the normal values. It is also observed that on the same date, they have done ABG test and PO-2 test at 9-50 AM. The result is below the normal range i.e. PO-2 is 46.6 and its minimum range should be 75-100 and O2 SAT result is 89.7 and the normal range should be 95-98. Again, at about 6-30 PM of 30.6.2011, they have done ABG test, in which the PO-2 is 65.9 and O2 SAT is 93.5. On 1.7.2011, at about 7-13 AM they have done the tests under department of chemical pathology, the platelet count was 110000 which is below the normal value. On the same day around 9-30 AM, they have done the ABG test, in which the PO2 shows 47.6 and O2 SAT 89.9. These results are below the normal range. Again on 2.7.2011, they have done the ABG test at 8-50 AM and PO2 is 60.2 and O2 SAT is 93.2. The same test was done again on 3.7.2011, PO2 is 58.4 and O2 SAT is 92.1. Again on 4.7.2011, the opposite party did ABG test and its result is PO2 is 49.1 and O2 SAT is 86.8, which is also below the normal range. Several other tests are also conducted and those tests are normal in range. At the request of complainant, this Forum sent Ex.A2 prescriptions to Superintendent, General Hospital, Kakinada to give the details of use of medicines, which are used in Ex.A2 to the complainant. The Professor and Head of the Department of Pharmacology, Rangaraya Medical College, Kakinada gave a detailed use of medicines administered to the complainant, in which they have given details of the medicines which have to be used on what occasion. As per P.W.2 examination, he clearly mentioned that the complainant is a smoker and even before the injury, he was having airway disease may be due to smoking. He also stated that because of chronic pulmonary disease, the improvement of pressure of oxygen in blood is delayed. They also stated that the platelet count is one of the parameter to be considered before surgery. He also stated that on the date of arrival to NIMS Hospital, the patient was conscious and coherent, vital stable with decreased oxygen saturation. Because of low saturation and the repeated ABGS, PO2 was vary from 58-90, this was probably because of pulmonary Thrombo Embolism on the background of chronic obstructive airway diseases. After improvement of the ABG and PO2 levels, they operated the complainant on 15.7.2011 and 20.7.2011.

As per the documents filed by the complainant in Ex.A1, it is clearly mentioned that the complainant sustained multiple fractures due to fall from the 5^th floor. Initially, he was admitted in Sai Orthopedic Hospital for the first aid and then shifted to the opposite party hospital with hypertension. In Ex.A2 discharge summary, they stated that the ABG not showing much improvement with oxygen and other supportive measures. P.W.2 also stated that before the patient is stabilized for surgery, pin traction could be applied and also stated to immobilize the fracture bones as any such movement may increase fat embolism. The opposite party contended that they discharged the complainant to higher center i.e. NIMS for further management in view of not improving from Hypoxia (continuous low levels of PO2) in ABG.

In view of the above discussion, we observed that the complainant was accidentally fall from 5^th floor and was immediately joined in Sai Hospital for first aid and later shifted to the opposite party hospital on the advice of Dr. R. Partha Sarathi.  But, the complainant has not joined him to the proceedings as he referred the complainant to admit in the opposite party’s hospital.  The complainant also contended that Dr. Partha Sarathi is a penal doctor, but he has not filed any proof of document before this Forum.  As seen from Ex.B1, it is observed that the oxygen levels in the blood and also the platelets are very low than the normal range of the complainant. In this case, the complainant had multiple fractures due to fall from 5^th floor.  Due to severe injuries, it will take some time to stabilize the health of any patient for conducting the surgery. The P.W.2 is also stated that because of low level of ABG and PO2, the surgery could not be done because the patient cannot be given anesthesia in that situation.  In NIMS Hospital also, they conducted the surgery seven days after joining into the hospital. They also did ABG test for several times to monitor the levels of oxygen in blood and the condition of lungs.  After conducting the lung test on 14.7.2011 and its result was negative then only the doctors of the NIMS conducted the surgery to the complainant. As seen from the record, the main parameters i.e. ABG result and platelet counts are very low while the complainant was in the opposite party hospital. The Government hospital, Kakinada sent a detailed report with regard to the medicines prescribed by the opposite party, but, in this report, the Professor and Head of the Department of Pharmacology, Rangaraya Medical College, Kakinada never said that the opposite party gave excess medication to the complainant. In this, they only said which medicines to be used for which complaint. If they have examined the above said doctor whether the opposite party has given correct treatment or not to the complainant then only we can come to a conclusion that the opposite party has not given proper treatment to the complainant in those seven days. But, the complainant has not examined the doctor who gave the report.  It is also observed that P.W.2 stated pin traction is very essential prior to the surgery to increase fat embolism. In this case, Dr. Partha Sarathi applied pin traction to the complainant on 2.7.2011 to relieve pain and to prevent shortening till the time the patient becomes fit for surgery. All the prescriptions filed by the complainant i.e. Ex.A7 are issued by Dr. Partha Sarathi.  But, the said doctor was not added as a party in this case. As per the record, the opposite party constantly monitoring the condition of the complaint and doing necessary tests.

Basing on the above discussion, we opined that there is no deficiency of service on the part of the opposite party in treating the complainant and he is not entitled for any reliefs. Hence, the complaint is liable to be dismissed.        

 

 

8.   POINT No.3:  In the result, the complaint is dismissed, without costs.   

         Typed to dictation, corrected and pronounced by us in open Forum, on this the 15^th day of March, 2016.

    

                Sd/-xxx                                                                                     Sd/-xxx

              MEMBER                                                                              PRESIDENT(FAC)

         

 

APPENDIX OF EVIDENCE

 

WITNESSES EXAMINED

 

FOR COMPLAINANT: .                                           FOR OPPOSITE PARTY:   None

 

P.W.1 :  Esukapatla Suni Syam Sundar

              Satya Keerthi Raju (complainant)

 

P.W.2 :  Dr. Raju Iyanger, M.S. Ortho,

              NIMS, Hyderabad.

 

DOCUMENTS MARKED

 

FOR COMPLAINANT:

 

Ex.A1      Admission summary issued by the opposite party dt.29.6.2011.

Ex.A2      Discharge summary issued by the opposite party dated 7.7.2011.

Ex.A3      Cash bill issued by the opposite party dated 9.7.2011 under Bill No.98.

Ex.A4      Further check up summary issued by Chakardhar Hospitals, Rajahmundry dated

                9.9.2011.

Ex.A5      office copy of the legal notice got issued by the complainant to the opposite party

    dt.19.1.2012.

Ex.A6      Returned cover of the opposite party dt.20.3.2012.

Ex.A7      Prescriptions issued by the opposite party in 10 numbers.

Ex.A8      Computerized medical bills (Pharmacy receipts) issued by the opposite party for

    Rs.15,230/- along with one printed cash bill.

Ex.A9      Laboratory bills issued by the opposite party 15 in number of Rs.9,080/-.

Ex.A10   Medical Certificate issued by NIMS Hospital dt.26.8.2011.

Ex.A11   Medical Certificate issued by NIMS Hospital dt.29.8.2011.

Ex.A12   Two Nos. of Discharge Record.

Ex.A13   Essentiality Certificate issued by Dr. Vijaya Saradhi.

Ex.A14   Essentiality Certificate issued by Dr. Raju Iyyangar.

Ex.A15   Radiometer ABL 800 Basic Report.

Ex.A16   CT Scan Request Form dt.8.7.2011.

Ex.A17   Lung Perfusion Scintigraphy Report dt.13.7.2011.

Ex.A18   Echo Cardiogram Report dt.12.7.2011.

Ex.A19   O.P. Services Bill-cum-Cash Collection details dt.8.7.2011.

 

Ex.X1  :  original case sheets pertaining to Sri E.S.S.S.S. Keerthi Raju bearing I.P.

                No.1116370/2011.

 

FOR OPPOSITE PARTY:-  

 

Ex.B1     Entire medical record i.e. Case sheet, Discharge summary, X-rays, wound

   certificate etc. pertaining to the treatment of Esukapatla Suni Syam Sundar Satya

   Keerthi Raju taken from 29.6.2011 to 7.7.2011.

 

                  Sd/-xxx                                                                 Sd/-xxx

               MEMBER                                                        PRESIDENT(FAC)