State Consumer Disputes Redressal Commission
Kiranashri, S/O. Late B. John, And ... vs Nellore Hospital,Rep. By Its Managing ... on 12 March, 2009
CC69 of 2007.html BEFORE THE A.P. STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD. C.C. No. 69/2007 Between: 1) Kiranashri, S/o. Late B. John Age: 58 years, Telugu Pandit 2) Deepthi Karanath S/o. B. Kiranashri, Age: 28 years 3) Smt. B. Kiranmai W/o. Z. Prashantha Kumar All are Residents of D.No. LIG 192, Sacred Heart School APHB Colony, Kallurupally A.K. Nagar S.O., Nellore-4. *** Complainants And 1) Nellore Hospital Aravinda Nagar Near RTC Bus stand Nellore- 524 003 Rep. by its Managing Director Dr. G. Vijay Kumar. 2) Dr. G. Vijay Kumar. Managing Director Nellore Hospital Aravinda Nagar Near RTC Bus stand Nellore- 524 003 3) Dr. Y. Krishna Mohan Rao Nellore Hospital Aravinda Nagar Near RTC Bus stand Nellore- 524 003 4) Dr. P. Jayarajan, MD., Civil Surgeon Specialist DSR Dist. H.Q. Hospital Consultant Aravinda Nagar Near RTC Bus stand Nellore- 524 003 *** Opposite Parties Counsel for the Complainant: M/s. V. Gourishankara Rao Counsel for the OPs: M/s. D. Krishna Murthy CORAM: HONBLE SRI JUSTICE D. APPA RAO, PRESIDENT & SMT. M. SHREESHA, MEMBER
FRIDAY, THIS THE TWELFTH DAY OF MARCH TWO THOUSAND TEN Oral Order: (Per Honble Justice D. Appa Rao, President) ***
1) This is a case of medical negligence.
2) The case of the complainant in brief is that complainant No. 1 is the husband, complainant No. 2 is the son and complainant No. 3 is the daughter of late Smt. M. Shantha Kumari, who worked as teacher. When she was suffering from fever and cough initially she was taken to Dr. N. Vivekananda, a family doctor who after getting clinical examinations and Real Time Ultra Sound of abdomen test referred to Dr. Murali Sankara Reddy of Anasuya Heart Care Centre suspecting that she had Congestive Heart Failure (CHF) and collection of fluid in the lungs, heart etc. On that he examined her and conducted tests which showed moderate pericardial effusion, left ventricular hypertrophy (enlargement), mild strain on the heart. While prescribing some medicines he directed her to undergo blood test for anaemia and other tests viz., Hierogram, Serum Electrolytes, LFT, TSH etc. and advised review. When she was unable to withstand the burning sensation in the abdomen etc. she was taken to OP2 who has been running Op1 hospital for second opinion, and for further treatment if necessary. He admitted her as in-patient in his hospital on 4.1.2007. Ops 3 & 4 were also attending on her.
They diagnosed as pulmonary tuberculosis with pericardial plural effusion and administered drugs such as RCnex, Mycobuta, Pyrizinamide and other drugs. Though there was no improvement she was discharged on 13. 1. 2007. She was administered saline bottles even on 17.
1.2007.
Op4 advised her absolute rest for one month from 18.1.2007 to 17.2.2007 and gave a certificate that she was suffering from Pulmonary Tuberculosis with T2 DM. She was continuing the drugs prescribed and on 20.1.2007 she had cough, vomiting and shortness of breath. On which she came to OP1 hospital at about 10.30 a.m. wherein she was diagnosed that she was suffering from Hypoglycaemia with shock. There they advised that she be shifted to a higher centre for better management. Accordingly, she was admitted in Bollineni Ramanaiah Memorial Hospital, Nellore on 20.1.2007 in the midnight where Dr. V. Sailender Chakravarthy conducted necessary investigations.
However, she expired at 4.45 a.m. He issued the death summary mentioning that the cause of death was Severe metabolic acidosis and cardiomyopathy. There was a mention that there was no signs of TB From this it is clear that the opposite parties had diagnosed wrongly and gave anti-tuberculosis treatment instead of treating her for heart problem. No treatment was given for the actual ailment she was suffering viz., heart ailment. This constitutes deficiency in service and on that they gave legal notice claiming compensation of Rs. 25 lakhs alleging deficiency in service and wrong diagnosis. She was 51 years at the time of her death. Besides loss of income, the children lost the love and affection of their mother. They paid Rs. 8,000/- towards treatment besides other charges. Therefore they prayed that a compensation of Rs. 25 lakhs be awarded and costs of Rs. 20,000/-.
3) Opposite Parties resisted the case. While denying each and every allegation made by the complainants, they asserted that there was no deficiency in service on their part. They rendered best professional service. She was discharged from the hospital only after she was recovered fully. When she came to the hospital for the first time on 4.1.2007 she brought the prescription of Dr. Vivekananda who treated her with antibiotics of Genatmycin and referred her to Dr. Muralisankar Reddy a Cardiologist who treated her for five days with antibiotics and heart ailment drugs. He in fact, referred her to a Physician for further examination. The tests conducted earlier would undoubtedly show Concentric LVH i.e., enlargement of the heart in echo and raised ESR of 135 mm/hr. She also had Pleural effusion i.e., fluid in the coverings of the lungs) and Pericardial effusion i.e., (fluid around the heart), chronic heart failure according to the Ultrasonogramme and other records. She was severely sick as such she was admitted in Critical Care Unit for two days and after improvement she was shifted to the room. She was also a diabetic. In spite of administering antibiotics there was no improvement, and therefore they suspected Tuberculosis. They strictly followed the protocols of Revised National Tuberculosis Control Programme (RNTCP) by conducting three sputum examination tests, chest X-Ray and other tests. The tuberculosis antibody tests IGM and ICG came positive. As there was no response to antibiotics, they suspected to be a case of Tuberculosis in spite of negative sputum tests. As physicians they are entitled to make a decision to treat for tuberculosis in spite of non-indicative of chest X-Ray and negative sputum tests. They rightly gave treatment for tuberculosis in addition to treatment for heart ailment. In fact BRM hospital also continued the treatment for tuberculosis. She was treated with tuberculosis drugs like Rifampicin, ethambutal, INH and Pyrazinamide. They gave treatment for heart complaint by prescribing the drugs like Lasix, Deriphyllin, Toresmide and Ramipril (ACE inhibitor) exclusively to deal with the load on the heart, to prevent heart failure and to treat heart ailment. She in fact was improved with the above said treatment, and after she became normal she was discharged on 13.1.2007. She was directed to continue the said drugs and come for review after one month. When she was brought again on 17.1.2007 with a complaint of nausea and water brash OP4 on examination found that there was gastric disturbance and water brash, and directed to get her readmitted. However they refused to admit her despite doctors persistence.
Again on 20.1.2007 she came with complaints of breathlessness, sweating and vomiting. It was found that patient was in a shock with very low blood glucose levels of 23 mgs%. By then there was loss of valuable time. On that she was advised to take her to a multi speciality hospital having different branches. They gave proper treatment with utmost care after conducting all necessary tests. There were no omissions or commissions on their part. The allegation that treatment for tuberculosis can only be given only if sputum test showed positive is incorrect. There are instances where the sputum test for pulmonary TB patients comes negative. Chest X-Ray was also inconclusive. A physician has to decide the medicines to be administered after considering the various symptoms. They administered proper drugs. A suitable reply was given to the notice issued by the complainant. There was no medical negligence on their part. They treated her with utmost care, and they were not liable to pay any compensation, and therefore prayed for dismissal of the complaint with costs.
4) The complainants in proof of their case examined the husband of the deceased as PW1 and examined Dr. B. Bhaskar Rao as PW2 and got Exs. A1 to A21 marked. The opposite parties examined OP2 as RW1 and filed Ex. B1 case sheet. Exs. X1 case sheet issued by Bollineni Super Speciality Hospital and Ex. X2 pharmacy receipt issued by BRM hospital are marked.
5) The points that arise for consideration are:
i) Whether the opposite parties had wrongly diagnosed that the patient was suffering from T.B, and wrongly administered the medicines that led to her untimely death?
ii) Whether the complainants are entitled to any compensation?
iii) If so, to what amount?
iv) To what reflief?
6) It is an undisputed fact that Smt. M. Shantha Kumari (deceased) wife of complainant No. 1 and mother of complainant Nos. 2 & 3 a teacher admitted in Op1 hospital. OP2 is its Managing Director. Ops 3 & 4 are experts attached to Op1 hospital. When she was suffering from fever and cough, initially she was taken to their family doctor Dr. N. Vivekananda who after conducting routine blood, urine and ultra sound of abdomen tests Exs. A3 and A4 suspected that she has congestive heart failure (CHF) and collection of fluid in the lungs and heart etc. He referred her to another doctor Dr. Murali Sanakara Reddy of Anasuya Heart Care Centre. Dr. Murali Sanakara Reddy in his turn got Echo test Ex. A5, ECG test Ex. A6 and other tests and found left ventricular hypertrophy (enlargement), mild T/R. He prescribed medicines and advised review. He treated her for four days and the particulars of his treatment were mentioned in Ex.
A8. The complainant alleged that as there was acute reaction and unable to contain the intensity of those drugs she became very weak admitted to O.P. No. 1 hospital for treatment. The complainant did not allege any negligence, nor impleaded the above said doctors.
7) It is an undisputed fact that the opposite parties had treated the patient from 4.1.2007 to 13.1.2007 in their hospital as in-patient. They assert that their diagnoses do show that she had tuberculosis (TB) besides heart ailment and gastritis. They administered tuberculosis drugs like Rifampicin, Ethambutal, INH and Pyrazinamide. They also administered Lasix, Deriphyllin, Torsemide and Ramipril to deal with heart ailment and Rantidine for severe acidity.
She was discharged on 13.1.2007 prescribing the medicines to be administered for one month and asked to come for review after one month vide Ex. A9. It is not in dispute that on 17.1.2007 she visited once again where according to the complainant except administering saline she was not treated well. In fact OP4 gave a certificate Ex. A12 on 18.1.2007 stating that the patient was suffering from pulmonary tuberculosis with T2 DM advising absolute rest for one month from 18.1.2007 to 17.2.2007 for the restoration of her health. He prescribed drugs and advised to again come for review after one month. While so on 20.1.2007 she came once again to O.P. No. 1 hospital. She was suffering from cough, vomiting and shortness of breath, and on finding that she had hypoglycaemia with shock they treated her with proper medicines and advised PW1 to take her to a super speciality hospital for better management vide Ex. A13.
8) However when she was admitted in BRM Hospital at Nellore on the intervening night of 20/21.1.2007 she died at about 4.45 a.m. on 21.1.2007 due to severe metabolic acidosis and cardiomyopathy clearly mentioning that there was no signs of tuberculosis (PT) vide Ex. A16.
9) The complainant taking inspiration from Ex. A16 alleges that the opposite parties administered drugs unnecessarily for tuberculosis which she was not suffering and there was no basis for them to give treatment for such disease. They did not conduct sputum test and C.T. Scan of lungs which are mandatory. Due to administration of unwanted T.B. drugs her death was hastened ultimately led to cardiac arrest and death, and therefore liable to pay compensation.
10) PW1 the complainant no doubt reiterated these facts got those documents marked, however, he is not an expert in medicine, and he is a Telugu Pandit. His evidence is useful to evaluate the compensation besides the fact that he had taken his wife to several hospitals for treatment. He examined PW2 Dr. B. Bhaskara Rao, Managing Director of BRM Hospital, Nellore to prove that the deceased was not suffering from tuberculosis. However unnecessary medicines were administered which led to her death.
11) Undoubtedly, PW2 is an expert and his evidence would be of help to resolve the question whether the opposite parties had diagnosed wrongly and gave incorrect treatment. Before adverting to the evidence of PW2 we may state that opposite party No. 2 filed his affidavit evidence justifying their diagnosis and treatment filed Ex. B1 case sheet maintained by them.
12) The question now centres around to the treatment given by the opposite parties and when they admittedly administered the anti tuberculosis medicines whether they are guilty of medical negligence?
13) It is an undisputed fact that RW1 one of the doctors who treated the patient had prescribed medicines for PTB which according to the complainant she was not suffering from and as such the very administration of anti T.B drugs was incorrect. It was a wrong diagnosis and wrong treatment which led to her death. RW1 filed Exs. A20 & A21 X-Rays and insisted that these photographs would show that there was T.B. Though he alleged that sputum test was conducted, however, the report does not find place in the discharge summary Ex. B1. Opposite Party No. 4 Dr. P. Jayarajan issued a certificate Ex. A12 on 18.1.2007 mentioning that the patient was suffering from pulmonary tuberculosis with T2 DM advising absolute rest for one month from 18.1.2007 to 17.2.2007 for restoration of her health.. Later on 20.1.2007 when she came with hypoglycaemia with shock and thereupon they directed to refer her to a super speciality hospital. Accordingly she was admitted in BRM Hospital on 21.1.2007. In Ex. A16 death summary maintained by BRM Hospital, Nellore wherein they have categorically mentioned that:
A 50 years old female came with a complaint of fever since 1-1/2 months, cough with expectoration vomiting and SOB since morning i.e. 20.1.2007 on examination BP not recordable on dopamine and dobutamine ABG revealed severe metabolic acidosis corrected accordingly. Suddenly developed respiratory arrest and incubated and followed cardiac arrest all active steps taken. In spite of all this patient could not be revived and declared dead at 4.45 a.m. They have also conducted various investigations. According to them the cause of death was Severe Metabolic Acidosis and Cardiomypathy. Importantly they have mentioned that there was no signs of PT meaning TB.
14) Before admission in the hospital, abdomen scan test etc. were taken by some other doctors, and they were of the opinion that Tenderhepatomegally with preominent IVC, Bilateral Pleural Effusion, Ascites and Pericardial Effusion The patient was taken to Anasuya Heart Care Centre. In fact Dr. NHV Vivekananda advised 2D-Echo colour Doppler test which shows Concentric LVH, Mild Tricuspid Regurgitation, Moderate Pericardial Effusion. He prescribed medicines and advised review. While she was undergoing treatment with him from 31.12.2006 to 3.1.2007 she developed burning sensation, and unable to bear it, she came to opposite parties hospital for treatment. Basically the opposite parties continued the very same treatment, besides administering anti T.B. drugs, in view of the fact that X-Ray suggestive of PTB.
The complainants allege that without conducting sputum test administration of anti T.B. drugs was wrong. They did not administer correct medicines for her ailment which led to her death. Therefore this amounts to deficiency in service on their part.
15) In order to prove the said fact they examined Dr. B. Bhaskar Rao of BRM Hospital where the patient died. As we have earlier pointed out that they have categorically stated that there was no signs of PT. The complainants was of the opinion that the diagnosis was wrong. PW2 was examined by the complainants in order to prove the deficiency in service. It is important to note that PW2 in his evidence deposed that:
The patient was diagnosed that she was suffering from severe metabolic acidosis which means derangement of blood chemistry. At 4.45 a.m. on 21.1.2007 the patient expired in our hospital.
As a part of treatment we have given injection Streptomycin 0.75 grm, IM, Tab. Lenotech 750 mg, Tab. Ecox 800 mg. Nebulization, Asthaline+ Viprovent+ Respule, every second hour. Inj. Deriphline 1 ampoule IV, Inj. Dopamine drip 10 15 micrograms per Kg, per minute to be increased gradually if necessary, Inj. Dobutamine drip 10 micrograms per Kg per minute, Intra venous fluids, Dextrose normal saline, Ringer lactage 125 ml per hour.
It is true to suggest that in death summary ( Ex. A16) we have mtnioned the X-Rays findings as cardiomegaly and no signs of PT (Pulmonary Tuberculosis) Inj. Streptomycin, Tab. Lenotech, Tab. Ecox were the drugs meant for tuberculosis. But case sheet does not reveal about the administration of the said drugs to the patient. As per the case sheet, the cause of death is not recorded as pulmonary tuberculosis. But it was mentioned that severe metabolic acidosis and cardiomyopathy were the causes for the death of the patient. Cardiomyopathy means dysfunction of heart. The diagrams of the chest X-Ray and its findings in the case sheet were recorded by Dr. Sailnder Chaktravarthy, as per the old ECHO test and USG reports done outside this hospital, the findings were mentioned in our case sheet as Concentric LVH, Ascites, pericardial effusion, pleural effusion. In case of heart problem there will be accumulation of fluid in the pericardium, and pleural cavity, peritoneal cavity.
16) Since the contention of the complainants all through was that she was not given treatment for heart ailment and was concentrated only on anti T.B. drugs and therefore there was wrong diagnosis and ultimately ended in her death.
PW2 their own experts evidence admitted that:
It is true that according to training module of RNTCP (Revised National Tuberculosis Control Programme) June, 2006 in page No. 11 it is stated that on an average 10% TB suspects are expected to have sputum positive pulmonary TB. That means 90% of TB suspect patients are sputum negative. It is true in the case of Smt. Shantha Kumar common causes for prolonged fever like Malaria Leptospira and Typhoid and 3 sputum test etc. were tested and proved to be negative in Nellore Hospital. It is true that tuberculosis is more common in diabetics and Smt. Santha Kumar is a known diabetic.
17) PW2 himself admitted -
It is true to suggest that IgG and IGM are one of the high end immunological tests conducted in many diseases including T.B. It is true to suggest that in case of Smt. Shantha Kumar one can suspect TB because of both IgG and IGM are positive in the blood test conducted in the Nellore Hospital.
It is true to suggest that it is difficult to diagnose condition like PTB on bed X-Ray film taken in our hospital unless there is a severe complications of PTB like cavitary lesions and destroyed lung. Any patient who is having severe breathlessness unable to hold breath to get a good quality X-Ray in the X-Ray department, it is very difficult to comment on this bed X-Ray about the minute nature of the TB disease.
Major problems like severe pleural effusion and massive pneumothorax can be diagnosed.
It is true to suggest that the patient was brought to this hospital in severe breathlessness condition and in such a condition there is no warranty to take a regular X-Ray because we loose precious time to treat the patient in emergency situation. It is true to suggest that 2 to 3 weeks of treatment to a patient is sufficient for the disappearance of early TB findings in the X-Ray.
In the case of Smt. Santha Kumari in view of her past history it is very much essential for any doctor to treat the patient with tuberculosis treatment, as mentioned, the symptoms and signs in our case sheet in our hospital which is marked is Ex. X1.
It is true to suggest with the signs and symptoms of the patient not to treat with anti tuberculosis treatment and prolong the disease to exist in the body can cause severe complications like pulmonary cavitation and destruction of the lung. It is very difficult to confirm the diagnosis of PTB in early period of the disease either by sputum test or by X-Ray chest.
It is true to suggest that an X-Ray and medical officers judgement, one can be treated as sputum negative TB according to RNTCP & WHO. It is true as per Ex. X2 the attendants of the patient purchased anti TB drugs from our pharmacy within the hospital as prescribed by the doctor who attended on the patient. It is true that anti TB drugs were prescribed in our case sheet Ex. X1.
It is true as per the case sheet of Nellore Hospital, the patient was treated by drugs like Lasix, Dytor and Cardace (Ramipril) for heart ailment. It is true to suggest that the drug Cardace (Ramipril) is very much useful in patients with hear disease.
It is true that the discharge summary of the patient issued by doctors of Nellore Hospital clearly mentioned the diagnosis as TB, heart disease and diabetics and the treatment given and written in the discharge summary is in accordance with the diagnosis.
It is true to suggest that in spite of not mentioning in the death summary about TB as a cause of death does not mean that the patient did not suffer from TB.
18) When their own expert gave clean chit and approved the treatment given by the opposite parties, it is difficult to hold that there was wrong diagnosis and wrong treatment and therefore the opposite parties were liable to pay compensation.
19) Recently the Supreme Court in Kusum Sharma Vs. Batra Hospital & Medical Research Centre reported in 2010 (1) CPR 167 (SC) held that :
73. In Hucks v. Cole & Anr. (1968) 118 New LJ 469, Lord Denning speaking for the court observed as under:-
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.
74. In another leading case Maynard v. West Midlands Regional Health Authority the words of Lord President ( Clyde) in Hunter v. Hanley 1955 SLT 213 were referred to and quoted as under:-
In the realm of diagnosis and treatment there is ample scope for genuine difference of opinion and one man clearly is not negligent merely because his conclusion differs from that of other professional men...The true test for establishing negligence in diagnosis or treatment on the part of a doctor is whether he has been proved to be guilty of such failure as no doctor of ordinary skill would be guilty of if acting with ordinary care...".
The court per Lord Scarman added as under:- "A doctor who professes to exercise a special skill must exercise the ordinary skill of his specialty. Differences of opinion and practice exist, and will always exist, in the medical as in other professions. There is seldom any one answer exclusive of all others to problems of professional judgment. A court may prefer one body of opinion to the other, but that is no basis for a conclusion of negligence."
75. The ratio of Bolams case is that it is enough for the defendant to show that the standard of care and the skill attained was that of the ordinary competent medical practitioner exercising an ordinary degree of professional skill. The fact that the respondent charged with negligence acted in accordance with the general and approved practice is enough to clear him of the charge. Two things are pertinent to be noted. Firstly, the standard of care, when assessing the practice as adopted, is judged in the light of knowledge available at the time (of the incident), and not at the date of trial. Secondly, when the charge of negligence arises out of failure to use some particular equipment, the charge would fail if the equipment was not generally available at that point of time on which it is suggested as should have been used.
76. A mere deviation from normal professional practice is not necessarily evidence of negligence
20) The Supreme Court finally opined :
81. It is a matter of common knowledge that after happening of some unfortunate event, there is a marked tendency to look for a human factor to blame for an untoward event, a tendency which is closely linked with the desire to punish. Things have gone wrong and, therefore, somebody must be found to answer for it. A professional deserves total protection. The Indian Penal Code has taken care to ensure that people who act in good faith should not be punished. Sections 88, 92 and 370 of the Indian Penal Code give adequate protection to the professional and particularly medical professionals.
V. In the realm of diagnosis and treatment there is scope for genuine difference of opinion and one professional doctor is clearly not negligent merely because his conclusion differs from that of other professional doctor.
VI. The medical professional is often called upon to adopt a procedure which involves higher element of risk, but which he honestly believes as providing greater chances of success for the patient rather than a procedure involving lesser risk but higher chances of failure. Just because a professional looking to the gravity of illness has taken higher element of risk to redeem the patient out of his/her suffering which did not yield the desired result may not amount to negligence.
VII. Negligence cannot be attributed to a doctor so long as he performs his duties with reasonable skill and competence. Merely because the doctor chooses one course of action in preference to the other one available, he would not be liable if the course of action chosen by him was acceptable to the medical profession.
The entire record would undoubtedly show that the treatment given by the opposite parties was on an accepted line of treatment supported by the very evidence of PW2. Therefore, we are of the opinion that there was no negligence on the part of opposite parties while treating the diseased. We do not see any merits in the complaint.
21) In the result the complaint is dismissed. No costs.
1) _______________________________ PRESIDENT
2) ________________________________ MEMBER APPENDIX OF EVIDENCE WITNESSES EXAMINED FOR COMPLAINANTS: OPPOSITE PARTIES PW1; B. Kiranashri RW1; Dr. G. Vijay Kumar.
PW2; - Dr. B. Bhaskara Rao Exhibits marked for complainant:
Ex.A-1 Reference letter Dr. N. V. Vivekananda.
Ex.A-2 Haemotology report dt.30.12.2006.
Ex.A-3 Urine examination report dt.30.12.2006.
Ex.A-4 Ultra Sound Report dt.30.12.2006.
Ex.A-5 2D Echo Report dt.30.12.2006.
Ex.A-6 ECG report dt.31.12.2006.
Ex.A-7 Complete blood picture Report dt.3.1.2007.
Ex.A-8 Registration Data/O.P Card issued by Anasuya Heart Care Centre dt.31.12.2006.
Ex.A-9 Discharge summary issued by Nellore Hospital.
Ex.A10 TB IGG & IGM Report dt.4.1.2007.
Ex.A11 Prescription dt.17.1.2007 issued by OP.No.4.
Ex.A12 Certificate dt.18.1.2007 Ex.A13 Prescription card reference advise given by OP.No.1 dt.20.1.2007.
Ex.A14 Investigation reports of Bollineni Hospital.
Ex.A-15 & 16 Death Summary dt.21.1.2007 issued by Bollineni Hospital.
Ex.A-17 Legal notice dt.1.6.2007 issued to the opposite party.
Ex.A-18 Reply legal notice issued by the opposite party dt.27.6.2007.
Ex.A-19 Revised National Tuberculosis Control Programme chart.
Exs.A-20 X-ray taken at OP.No.1 hospital dt.4.1.2007.
Ex.A-21 X-ray taken at Bollineni Hospital dt.21.1.2007.
Exhibits marked for opposite parties Ex.B-1 Case Sheet issued by Nellore Hospital & Research Centre.
Marked through Advocate Commissioner:
Ex.X-1 Case sheet issued by Bollineni Super speciality Hospital.
Ex.X-2 Pharmacy receipt issued by B.R.M Hospital Pvt. Ltd., dt.21.1.1987.
1) _______________________________ PRESIDENT
2) ________________________________ MEMBER Dt. 12, 3, 2009.
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