National Consumer Disputes Redressal
M. Muniraja & 2 Ors., vs M/S Mallige Medical Centre Hospital & 7 ... on 25 July, 2024
NATIONAL CONSUMER DISPUTES REDRESSAL COMMISSION NEW DELHI CONSUMER CASE NO. 156 OF 2013 1. M. MUNIRAJA & 2 ORS., S/o Shri Mukundappa, R/o 47/2, Swasthi, Main Road, Shanthinagar, BANGALORE - 560027. ...........Complainant(s) Versus 1. M/S MALLIGE MEDICAL CENTRE HOSPITAL & 7 ORS., Through its Proprietor, Dr. Sreeramaiah, No. 31/32, Crescent Road, BENAGALOORU. 2. THE ADMINISTRATOR, M/s Mallige Medical Centre Hospital, No. 31/32, Crescent Road, BENAGALOORU. 3. DR. MUTHU, ORTHOPEDIC SURGEON, M/s Mallige Medical Centre Hospital, No. 31/32, Crescent Road, BENAGALOORU. 4. - - - 5. DR. MAHESH KUKREJA, ANESTHETIST, M/s Mallige Medical Centre Hospital, No. 31/32, Crescent Road, BENAGALOORU. 6. - - - 7. DR. RAVIGOPALA VERMA, M. S. Ramaiah Memorial Hospital, MSRIT Post, New BEL Road, BENAGALOORU. 8. M. S. RAMAIAH TEACHING & MEMORIAL HOSPITAL, Through its Joint Medical Director, MSRIT Post, New BEL Road, BENAGALOORU. 9. THE KARNATKA MEDICAL COUNCIL, No. 70, 2nd Floor, Vaidyakeeya Bhavana, K. R. Road, (Near Basavanagudi Post Office), Basavanagudi, BANGALORE. 10. THE MEDICAL COUNCIL OF INDIA, Sector 8, Dwarka, NEW DELHI. ...........Opp.Party(s)
BEFORE: HON'BLE MR. JUSTICE RAM SURAT RAM MAURYA,PRESIDING MEMBER HON'BLE BHARATKUMAR PANDYA,MEMBER
FOR THE COMPLAINANT : MR. PUNEET JAIN, MR. ASHWIN V. KOTEMAH,
MS. AKRITI SHARMA, MR. MANN ARORA, ADVOCATES FOR THE OPP. PARTY : MR. E.C. VIDYASAGAR, ADVOCATE AND
MR. SUBHASH CHANDRA SAGAR, ADVOCATE FOR OP-1&2
MR. RADHAKRISHNA S. HEGDE, ADVOCATE FOR OP-3&4
MR. D.P. CHATURVEDI, ADVOCATE FOR OP-5&6
Dated : 25 July 2024 ORDER
PER BHARATKUMAR PANDYA, MEMBER
1. The present complaint under Section 21 of the Consumer Protection Act, 1986 has been filed against the opposite parties - hospital and its doctors for medical negligence resulting in permanent vegetative state of Smt. Shailaja, wife of complainant no. 1.
2. As per the complainant, on 27.11.2009 Smt. Shylaja wife of complainant no. 1 and mother of complainant no. 2 and 3, suffering from low backache, approached OP No. 3 Dr. Muthu, Orthopedic Surgeon for medical advice. OP 3 advised her CT Scan and MRI, which she did on the same day and met Dr. Muthu and showed him the reports. Doctor diagnosed her with problem of spinal cord L-4 and L-5 and advised for an operation and to get admitted in the nursing home for three days. Ms. Shylaja got admitted in OP 1 hospital on 29.11.2009 at 9 a.m. by depositing Rs.35,000/- as an advance. She was operated on 30.11.2009 at around 6.30 a.m. and later shifted to the ICU by 930 am and was put on ventilator for artificial breathing. Treatment continued for about 15 days. Thereafter the patient was weaned off from ventilator and given oxygen support for about three months. She suffered serious brain damage inside Operation theatre and has never recovered therefrom. She remains in 'vegetative state' and needs feeding and endotracheal tubes and is able to respond only to painful stimuli. While in OP-1 hospital, whenever complainant no. 1's relatives enquired about her health status, attending doctors and other staff gave them some lame excuses and were not given any satisfactory reply about the line of treatment being given to the patient. Ultimately, he wrote a letter to the Administrator of the hospital requesting them to give the summary report about the pre-operative and post-operative treatment details. Summary treatment report dated 14.06.2010 was given which revealed that patient lost her consciousness on the very day of operation and was in a vegetative state from post operation period. On enquiry about her progress, OPs assured that she will regain her conscious soon. Even after treatment given by O.P. No. 1 to 4 for about 9 months, there was no marked improvement in health condition of Smt. Shailja. On 06.09.2010 complainant no. 1 wrote a letter to OP hospital for providing preoperative test reports and treatment details and also sent a reminder on 20.10.2010, which it appears were not responded. However, "somehow they managed" to get 'original records' through RTI, which disclosed that distraught supply of oxygen during the surgery is the main reason of present condition of the patient. On 12.11.2010, without prior intimation to the complainants, the patient was shifted from the hospital to a nearby building under the guise of giving her higher degree of neurological treatment. As per the complainant, hospital authorities locked the patient room and threw the belongings of the patient. A complaint was registered with the police for the illegal ill-motive acts of the OPs and a copy each of the same was also sent to Secretary, Ministry of Health, Karnataka and Chief Minister, Karnataka. Similar letters were also addressed to the Chief Minister, the Police Commissioner, Health Minister and its Secretary, Chairman, Women and Children Welfare and Karnataka Medical Council. As per the complainant, on 19.01.2011, OP 1 hospital shifted Smt. Shailaja to M.S. Ramaiah Hospital (OP 6) under the pretext of giving her higher neurological treatment and they assured complainants that all medical expenses will be meted out by them. However, later on OP 1 hospital through their correspondence dated 09.02.2011, 26.04.2011, 02.05.2011 and 07.05.2011 with OP 5 and OP 6 expressed that they will not be responsible for any medical expenses with regard to Smt. Shailaja. Being aggrieved, complainant filed a complaint before High Ground Police Station on 11.05.2011. On 18.06.2011, considering the seriousness of condition of Smt. Shailaja, Karnataka Medical Council directed M.S. Ramaiah Hospital to provide all medical treatment on humanitarian ground either at its hospital or at the hospital from where the patient is referred to it. Complainant filed Writ Petition No. 13711/2011 (GM Police) before the High Court of Karnataka. By its order dated 16.08.2011, High Court disposed off the matter by giving liberty to approach consumer courts for appropriate monetary reliefs and criminal action under the provisions of Code of Criminal Procedure in accordance with law. Negligence of the OP 3 and OP 4 were proved by findings of Karnataka Medical Council who held the OP4 Dr. Kukereja guilty of negligence vide order dated 22.08.2013 under which the name of OP 4 was directed to be erased from the Medical Registry for a period of one year. Complainants were forced to shift the patient from OP 6 hospital to their house on 04.11.2011. Patient is being treated at her house at their own expenses and day by day her health is deteriorating. Due to medical negligence of OP 1 to 4 and further due to inhuman attitude of OP 5 and 6, Smt. Shailaja is in a permanent vegetative condition, which has put the whole family under great injustice, inconvenience, mental and physical harassment and financial constraints. Being aggrieved, the complainants filed present complaint before this Commission on 16.05.2013 seeking a total compensation of Rs.1,86,48,190/- which is prayed for amendment vide IA 11511 of 2016 with the following prayer:
To direct the OPs, who are jointly and severally liable, to pay to the complainants compensation amount of Rs.5,99,00,000/- in addition to Rs.1,86,48,190/-, in all amounting to Rs.7,85,48,190/- with interest at the rate of 18% pa till the realization of the amount in the interest of justice and equity.
3. Opposite party no. 1 and 2 are the hospital and the administrative officer thereof who vide their written version dated 21.02.2014 (page 200) contended that when patient Smt. Shailaja came to their hospital for her problem of low backache, Dr. S. Muthu (OP-3), the orthopaedic surgeon in employment of OP-1 diagnosed that numbness in right lower limb was due to extruded disc and advised surgical treatment to remove the pressure on the spinal cord. The patient had voluntarily undergone the surgery on 30.11.2009 and that the pre-surgery routine check-up by the anesthetist and physician were duly carried out. Despite all the necessary state-of-the-art facilities available and skill and care exercised by OPs for performing surgery and post-operative care, very unfortunately, the patient developed postoperative complications during the period of recovery. The patient was attended to by Intensivist, Anaesthesiologist and physicians of every discipline needed. As per OP No. 1 and 2, they were continuously informing about the treatment of patient and her progress to complainant no. 1 on day to day basis. Later, when the need of higher neurological care was felt necessary, complainant no. 1 was informed about the same and advised to shift the patient to higher neurological rehabilitation centre for further management and treatment. A senior doctor from the OP hospital accompanied the relatives of the patient to meet director of NIMHANS, who is a well-known neuro-physician. But family of patient refused to comply with the advice of the OPs for higher neuro rehabilitation. On 14.06.2010 complainants were advised to shift the patient to higher neurological centre, which complainant no. 1 refused. Under duress, OP hospital lodged a police complaint dated 16.11.2010. It was with great difficulty that complainant no. 1 agreed and then patient was shifted to M.S. Ramaiah Medical College & Hospital on 05.02.2011. Thus, complainants themselves were responsible for deterioration in the health of the patient as they delayed following medical advice. Despite adverse atmosphere being created by the relatives of the patient, OP hospital still facilitated the admission of the patient to an advanced neurological centre and wrote letter dated 12.01.2011 to NIMHANS, Bangalore and dated 19.01.2011 to M.S. Ramaiah Hospital, Bangalore. The complainant no. 1 has paid only Rs.35,000/- towards the treatment of patient at the hospital and still Rs.8,71,175/- is pending from the side of the complainants, which they refuse to pay. Thus, the complaint totally lacks bonafides much less merits. Further, the anesthesia reversal drug is known to cause complication of arrhythmia and tachycardia and when it did occur to the patient, the same was expeditiously and efficiently handled as per prescribed protocol, the patient was resuscitated successfully and life was saved. No negligence can be inferred from a complication of a surgery or anesthesia as clearly mandated by Supreme Court in a series of decisions. There is no expert or medical evidence of negligence placed on record by the complainant. The Karnataka Medical Council has not found any negligence or medical misconduct on the part of the OP Hospital and even the adverse finding against OP4 has been stayed by Karnataka HC vide order dated 8.10.2013 (and subsequently also reversed by Medical Council of India). As per the treatment summary, the episode of tachycardia triggered by the reversal drug were promptly and efficiently handled in the OT saving the life of the patient and subsequent condition of the patient is solely due to such complication for which the OP Hospital or any treating doctor cannot be held negligent. The prescribed protocols were duly followed successfully and there is no evidence of any deviation or deficiency therein. Hence the complaint has no merits and is liable to be dismissed on merits.
4. OP No. 3 Dr. S. Muthu, who is Consultant Orthopedic Surgeon in OP 1 hospital, filed his written statement on 12.03.2014 (Page 253) stating that wife of the complainant no. 1 came to his OPD on 26.11.2009 complaining of low back ache with numbness in right lower limb since one year. Her MRI was taken which clearly indicated an extruded disc and compression on Thecal Sac at L4-5 level on the right side of ligamentation flavum hypertrophy. She was advised surgery to which she and her husband agreed and the surgery was done on 30.11.2009. Proper and informed consent was duly provided by the patient and her husband. Surgery was completed uneventfully and successfully and while giving her reversal drug to bring her back from the effect of anesthesia, she developed a neurological condition called Ventricular Tachycardia. As per OP 3, patient suffered this condition due to adverse effect of the anesthesia reversal drug though he carried out the surgery successfully and without any negligence. After surgery all vitals of the patient, i.e., BP, Heart rate, pulse, etc. were up to the mark. So all the allegations of careless treatment, non responding of the treating doctor, etc. are baseless and incorrect. Best possible treatment was given to the patient during all the time she was in the hospital. It has been categorically denied that the treatment summary report is self-styled, and the strict proof of the allegation is insisted. The surgery, which was indicated as per MRI report, was conducted after obtaining informed consent, after pre-surgery and pre-anesthesia investigations and after duly explaining the risk and probable complications and was successful. KMC, an expert body, has found no negligence on the part of OP-3 who has been duly exonerated. The complaint qua OP-3 is without merits and deserves to be dismissed.
5. OP 4 Anaesthetist Dr. Mahesh Kukreja also filed his written submissions on 12.03.2014 (page 276) wherein he did not admit any of the allegations made in the complaint. It is submitted that OP-4 has had more than 26 years of unblemished practice, he is head of department in medical college and has been incharge anaesthetist in more than 20000 surgeries. Proper pre-surgery anesthetic examination and investigations were carried out and the patient was normal and fully suitable for surgery and GA. in OT, patient was duly and constantly monitored with ECG, NIBP, SPO2. Endotracheal intubation and Guedel's airway were placed and secured which were re-confirmed and constantly monitored after the patient was placed in prone position for surgery. During surgery too, GA was maintained with 100% oxygen. After surgery, the patient was brought in supine position and thereafter only when patient started having spontaneous breathing, Myopyrolate, the reversal drug was administered in proper dosage. After 1 or 2 minutes, it was observed that that there was dysrhythmia which showed up as ventricular tachycardia. The prescribed protocol of injecting Dopamine, Hestar, Effcorlin and Sodium Bicarbonate, as required, including immediate consultation with physician Dr. Ravindran, was followed. After the sinus rhythm was achieved, the patient was shifted to ICU in unconscious state and was put on ventilator. Ventricular tachycardia is a known complication of reversal drug Myopyrolate which drug is required to be administered for reversing every GA, which fact can be appreciated from a series of medical articles and anesthesia chart enclosed with the reply. OP 4 carried out his professional duties with utmost care and diligence and followed all prescribed protocols to deal with the emergency/complication which arose due to reversal drug. The KMC's order dated 22.08.2023 holding the OP-4 guilty of medical negligence has been challenged by way of a a Writ Petition No. 45288/2013 before the Karnataka High Court. As such, there is no negligence or medical misconduct on the part of OP-4 and there is no merit in the complaint.
The Ethics Committee of Medical Council of India vide order dated 31.07.2020 unanimously exonerated Dr. Mahesh Kukreja from all charges of medical negligence levelled against him and observed as under:
After detailed deliberation, the Ethics Committee made the following observations:
Dr. Mahesh Kukreja is qualified and experienced Anesthesiologist.
Patient Shalja was posted for surgery on 30.11.2009 at Mallige Medical Centre for Fenestration Discectomy L4-5.
PAC done. Patient fit for GA. Patient positioned to prone from supine with all parameters maintained.
During the surgery all the vitals were well maintained in prone position as per the protocols.
At the end of the surgery, patient again positioned from prone to supine. Again clinical parameters maintained.
Patient had spontaneous effort for breathing with reversal agent with muscular relaxant for neuro muscular block.
Patient developed sudden dysrhythmia as ventricular tachycardia.
Reversal agent triggers dysrhythmia. Ventricular Tachycardia was treated with proper protocol and expert opinion of a physician was also taken inside the OT.
Patient was also given Injection Efcorlin 200 mg.
There was total reversal of VT to sinus rhythm and oxygen saturation improved to 95% along with PR and BP also improved.
Patient shifted to ICU for electric ventilation and further course of treatment.
It has also been noted that neo-stigmine may interfere with A V conduction even without high doses. To support this contention, a case report "Immediate Cardiac Arrest after Neo stigmine administration" has also been submitted which is on record.
In view of the above observations, the Ethics Committee after perusing all reports, investigations and other materials on record and after hearing both the parties at length unanimously decided to exonerate Dr. Mahesh Kukreja from all the charges of medical negligence levelled against him.
The above recommendations of the Ethics Committee have been accorded approval by the Board of Governors at its meeting held on 19.02.2020."
6. Opposite party no. 5 and 6 vide their written version dated 07.01.2013 (Page 185) submitted that there is no cause of action against them. Patient Smt. Shailaja got treatment of her lower back pain from M/s Mallige Medical Centre (OP 1 hospital) and she developed acute complications during the course of her treatment in that hospital. She was diagnosed with Hypoxic Encephalopathy during the course of her treatment in OP 1 hospital and was treated there from 29.11.2010 to 17.02.2011. She was brought to OP 6 hospital only on 17.02.2011 for neuro rehabilitation. When patient was admitted in OP 6 hospital, she had already suffered severe damage to her brain and thus she needed only nursing care and neuro rehabilitation. Patient was not obeying commands due to brain injury and there was rigidity of all four limbs. During her admission in OP 6 hospital, she once developed some respiratory infection for which she was treated in multi-speciality intensive care unit. As there was no improvement and no likelihood of further improvement in her general condition/ailment of brain damage, her relatives were advised to shift her to the home and accordingly she was discharged from OP 6 hospital on 01.06.2011. Medical Bill for the period of her admission from 17.02.2011 to 01.06.2011 for a sum of Rs.4,18,340/- still remained unpaid. The allegation made in the complaint that there was pressure from OP-5 doctor and OP-6 hospital for discharging Smt. Shailja is incorrect. In fact the condition of the patient had already deteriorated earlier to her admission in OP 6 hospital so no liability can be fastened upon OP 5 and OP 6 as they were not at all responsible for the vegetative conditions of Smt. Shailja. Hence, complaint against them should be dismissed with costs. In support of the objections raised, the copies discharge summary dated 17.02.2011 is filed therewith.
7. The complainants filed common rejoinder on 08.06.2018 (page 322) stating that patient Smt. Shailja was admitted in OP 1 & 2 hospital on 29.11.2009 wherein she went into coma and not regained her consciousness since then. She was very forcefully discharged from OP 1 & 2 hospital as well as OP 5 & 6 hospital. She is now being treated at her house by own expenses and her health is deteriorating day by day. It has been re-emphasized that the OP-1 and 2 have not supplied the documents sought by them namely the documents showing actual process during surgery of the patient in OT and further that distraught supply of oxygen during the surgery is the main reason for cause of present vegetative condition of Smt. Shailja. The cross-examination of Dr. Muthu and Dr. Kukreja (OP-3 and 4) before the KMC have been filed. In fact, the anesthetic flow chart which were supposed to disclose the flow of oxygen have not been supplied to them by the hospital which were obtained through RTI. it is prayed that the Complaint be allowed and compensation be given to them.
8. Parties led their evidences by way of affidavits and filed their written written synopsis. Complainant no. 1 by way of affidavit has exhibited Annexures 1-32. OP No. 1 and 2 have exhibited Annexures R-1 to R-8 and have also subsequently filed 13 page hospital papers after permission from the commission. OP-3 and OP-4 filed Annexure R-3/1 and Annexure P-4A to P4-E respectively along with written reply. OP Nos. 5 and 6 enclosed copy of discharge summary with reply. Parties further filed Affidavit of admission/denial.
9. We have heard the counsel for the parties and perused the documents on record. It has been contended by complainant no. 1 vide written arguments dated 20.04.2023 that his wife Smt. Shailaja underwent surgery on 30.11.2009 from OP 1 hospital and after surgery she did not regain consciousness and is in permanent vegetative state till date. She responds only to the pain stimuli but is unable to move any of her body part. Due to long bed ridden condition, her muscles have atrophied and she suffers from repeated chest and urinary infections. This painful and permanent condition of the patient is due to negligent failure of OPs 1-4 in constantly and diligently monitoring the oxygen supply to the patient during and after the surgery, Treatment Summary which is self-styled and which was provided to the compliant only after nearly 6 months of surgery, dated 14.06.2010, stated as under:
TREATMENT SUMMARY
NAME: MRS. B. SHYLAJA AGE 33 YEARS IP. NO. 184602
CONSULTANTS:
Dr. S. Muthu Orthopedic Surgeon
Dr. Mahesh Kukreja Anaesthetist
Dr. T S Ravindra Physician
Dr. B P Mrutyunjayanna Neurologist
Dr. Ravishankar ENT Surgeon
Mrs, B. Shylaja, aged 33 years, admitted on 29.11.09 with history of low backache radiating to right lower limb since one year. Numbness of right lower limb since a week. Clinically she had LS spasm, flexion limited & painful and SLR: R=30 L=N, no deficit.
MRI LS spine showed prolapse disc L4/5 right. After pre operative assessment patient was taken for Fenestration Discectomy L 4-5 right on 30.11.09. After the surgical procedure was completed successfully and patient was positioned in supine position, reversal of muscle relaxant was given. During recovery phase of anaesthesia, patient developed ventricular tachycardia with temporary/transient hypoxia and hypotension. ACLS protocol followed and resuscitated in OT, rhythm reverted to sinus rhythm, ventilated with 100% oxygen hypotension treated with steroids, colloids and inotropes. Patient was shifted to Intensive Care Unit, mechanically ventilated and monitored. Her GCS: 4/15. She was seen by Neurologist, Cardiologist and Intensivist. She was continued on supportive treatment, she received antiedema, anticonvulsants, sedation and neuroprotective drugs. 1st C. T. Scan Brain done on 01.12.09, which showed cortical sulci are slightly effaced? Mild edema. Subsequent CT Scan done on 03.02.10, which showed Bilateral symmetrical old external capsule and periventricular (sub ependymal) region infarcis, Ischemic changes in both occipital and left high fronto-parietal region, mild dilated both lateral and 3rd ventricles and mild diffuse cerebral atrophy.
A Neuro surgical consultation was taken. She underwent elective Tracheostomy on 09.12.09 under LA with sedation. Procedure was uneventful. Patient slowly improved in the form of spontaneous breathing, ABG was normal, lab parameters were normal and she maintained oxygen saturation on just T-piece. Her conscious level gradually improved to response to painful stimuli, opening eyes, pupillary reaction were normal and spontaneous movements were present. Later there was response to painful stimuli and other vital parameters were normal.
She was weaned off the ventilator on 14.12.09. Once patient was conscious, looking around and stable was shifted to ward.
She continues to be on Tracheostomy tube air way support as decannulation was not possible because of neurological condition of the patient. Tracheostomy tube was periodically changed.
Patient had respiratory tract infection, which was treated appropriately and the patient recovered completely from respiratory infection.
She was under the constant care of Intensivist, Neurologist and ENT Surgeon. At present, patient opens her eyes, moves eye balls in all direction, responds to painful stimuli, does not follow commands, pupils are reactive & normal in size, moves all her four limbs on her own. She can be made to sit on wheel chair. Her lab parameters are normal at present.
Presently patient has been advised to go to Higher Neurological Centre for further management and rehabilitation. This has been explained to the patient's husband. At present the medications, she is on are as follows:
1. Tab Levisam 500mg 1-0-1.
2. Tab Pantodac40mg 1-0-0.
3. Tab Lirotel XL 20mg 0-0-1.
4. Tab PTU 50mg 2-0-2.
5. Tab Frisium 10mg 0-0-1.
6. Tab Martifur 1-0-0.
7. Syrup Duphalac 15ml twice a day.
8. Syrup Nootrophil 10ml thrice a day.
9. Syrup Polybion 2tsp twice a day,
10 Syrup Valparin 10ml twice a day,
10. As per O.P. 1 to 4, in the OT, the patient developed ventricular tachycardia as an adverse side effect of Myopyrolate - the drug to reverse neuromuscular blockade. Due to ventricular tachycardia, she developed transient/temporary hypoxia resulting in her brain injury. Admittedly, the brain injury responsible for the condition of the patient is caused due to HYPOXIA. OPs contended that hypoxia occurred due to ventricular tachycardia which occurred due to side effect of MYOPYROLATE - the necessary and customary drug given to the patient to reverse the neuro muscular blockade after the surgery. The anesthesia chart clearly records the constant oxygen supply and the complication which did occur was diligently managed which saved the life of the patient.
11. Complainant on the contrary submitted that Myopyrolate is a common and most widely used drug to induce reversal of neuro muscular blockade after surgeries. Myopyrolate does not cause ventricular tachycardia as is suggested by the OPs in their reply. OP 4 Dr. Mahesh Kukreja in his cross examination before Karnataka Medical Council stated that the at the time of change of the patient from prone to supine, ventricular tachycardia was noticed - reversal of anaesthesia may trigger arrhythmia. Patient was unconscious at that time. It clearly shows that ventricular tachycardia was noted when patient was turned from prone to supine position and the reversal drug was given after turning the patient into supine position. Thus as per the evidence before the Karnataka Medical Council, ventricular tachycardia occurred prior to giving of Myopyrolate and therefore Myopyrolate could not have induced ventricular tachycardia. So it is concluded that if Myopyrolate was given in prone position, than it is a negligent act itself as the reversal of neuro muscular blockades are always given in supine position. Further, the distraught oxygen supply and the resultant hypoxia due to negligent and lack of care and caution by the OPs 1-4 before administration of Myopyrolate and during her prone position, is the real cause of even tachycardia, hence occurrence of complication of myopyrolate as suggested by OPs is not what actually transpired. The treatment and discharge summary provided to the complainant by OPs is a self-serving afterthought to put defence of complication which is not supported by any evidence.
12. Complainant further submitted that Hypoxia is lack of oxygen in the blood. Ventricular tachycardia does not cause Hypoxia rather Hypoxia causes ventricular tachycardia. When there is hypoxia, the heart starts beating faster (tachycardia) so that more blood and thereby more oxygen can be pushed to the organs. Thus Hypoxia results in tachycardia. The OPs are incorrect in submitting that Hypoxia was caused due to tachycardia whereas the fact of the matter is that Ventricular Tachycardia happened as there was lack of oxygen due to possible extubation and negligent and careless actions of the OPs 1-4 as noted by the Karnataka Medical Council in its order:
"...... The patient Smt. Shylaja was shifted from a prone position to the supine position and reversal muscle relaxant was given. During the phase of recovery patient developed ventricular Tachycardia, cerebral death due to Cerebral hypoxia and remains in the same state even to-day. Attempts were made by the Respondents to restore the hypoxic state but failed as it was too late. A Patient will suffer a Cerebral Death if the oxygen supply to the brain is not adequate for more than 3-4 minutes and it is irreversible and this is what exactly happened in the present case. Post operative C.T. Scan confirmed cerebellar and cerebral infarcts and atrophy.
The question before the Karnataka Medical Council:
(1) How Cerebral hypoxia could happen?
(2) Who is responsible?
(3) What Action?
Answers: (1) During the shifting of the patient from prone to supine position the endotracheal tube might have slipped leading to failure of supply of oxygen to the brain resulting in cerebral death. The other possibility could be that the patient while recovering from anesthesia may have bitten the endotracheal tube strongly. This could have happened for more than 3 to 4 minutes. To Question No. (2), R(1) the Orthopaedic Surgeon had performed Surgery without any complications.
It is the duty of the Anaesthesiologists to monitor the patient and keep a constant vigil on the vital parameters during and after surgery till the patient completely recovers from Anaesthesia. In the instant case, R(2) has failed to perform his duty and allowed the patient to go into cerebral hypoxia. The golden 3-4 minutes were lost resulting in cerebral death. R(3) has shown humanitarian consideration and treated the patient for 15 months.
ORDER
Karnataka Medical Council is of the unanimous Opinion that R(1) has been administered a "Warning" as he was practicing as an Orthopaedic Surgeon without registering his P.G. Qualification. R(2) was Negligent and his name has been erased from the Medical Registry for One year w.e.f. the date of this Order. R(3) has been Exonerated."
13. Complainant has further submitted that hypoxia results in brain injury and cerebral death only when it remains undetected and untreated for sufficiently long period of time of more than 5-6 minutes. Such unnoticed long duration hypoxia and the consequent permanent damage to brain of the patient cannot be explained by any complication of reversal drug and is in fact mere and direct consequence of gross negligence and callous carelessness of OPs 1-4 and other nursing attendants in the operation theatre. The unsubstantiated averment of OPs that patient developed tachycardia and further complications is an afterthought and imaginary defence to explain away the hypoxia and brain damage which in fact has occurred due to gross negligence in monitoring the proper oxygen flow and position of airway tube. As such, the complete damage to brain described by OP-5 in their admission notes and discharge summary as "hypoxic encephalopathy" and by KMC in their order as "cerebral death" could not have occurred unless the oxygen supply to brain i.e. respiration would have been completely cut-off for more than 5-6 minutes during which the experts and nurses in OT remained unmindful or clueless and made no efforts to set things right. Or, worse, as KMC has opined, everyone in OT, and particularly, OP-4 was completely careless and negligent when the endotracheal tube had slipped out or was bitten by the patient resulting in hypoxia and consequent damage to brain. Medically also hypoxia is a treatable condition/complication and in most cases, hypoxia does not result in cerebral injuries or death if properly and timely noticed and treated as per standard protocols in this behalf. There are modern medical equipments in OT which can even artificially and forcibly breath air into the lungs. It is only when the hypoxia remains negligently and recklessly unnoticed, unattended and untreated for long that "cerebral death" can occur. Therefore the present condition of the patient is wholly, patently and indisputably attributable to OPs 1-4 and thereafter to OP-5 and 6. It is further submitted that because a completely healthy and young lady of 33 years without any comorbidities admittedly suffered brain insult within 2 hours in the closed door operation theatre, what actually medically transpired is within the special knowledge of the OPs 1-4 who have joint burden of explaining the unlikely outcome by cogent evidences, but no such evidence is either provided when demanded by the complainants nor produced before this commission, which itself establishes the negligent and callous actions and inactions of the OPs. It is emphasized that no evidence in the form of doctors' chronological progress notes of the events, monitoring, consultations, diagnostic tests, evaluation and treatment in the operation theatre and in the ICU for 18 days and thereafter have been maintained, provided or produced by the OPs. Therefore they have completely failed not only in filing the contemporary or any evidence but also even in cogently explaining the events within their special and within their expert knowledge. Complainants have relied on the judgment of Kerala High Court in Dr. M.K. Gourikutty and etc. Vs. M.K. Raghavan & Ors. AIR 2001 Ker 398 decided on 08.08.2001, and emphasised that facts in his case are exactly identical. It is submitted that the negligence of OP-1 to 4 is palpably evident from the still unexplained event of vegetative state of the patient and that the case, parallelly with this case, required the OPs to place independent contemporaneous evidence on record to substantiate the explanation of the event, particularly so after Karnataka Medical Council held the OP-4 negligent and responsible for Ms. Shailja's condition and such evidence was already placed on record by the complainant. Reliance was placed on paras 13 to 16 of this decision and following para 16 was particularly re-emphasized:
16. As to what is brain anoxia, we refer to Harrison's "Principles of internal Medicine", Ninth Edition at page 1977. Anoxic Encephalopathy : This is one of the most frequent and disastrous accidents encountered in the emergency and operating rooms of every general hospital. The basic disorder is a lack of oxygen supply to the brain, the result of failure of the heart and circulation or of the lungs and respiration. Often both are responsible, and one cannot say which predominates -- hence the ambiguous allusion in clinical records to "cardiorespiratory failure". The condition which most often lead to anoxic encephalopathy are (1) suffocation (from drowning, strangulation, aspiration of vomitus or blood, surgical pack, or foreign body in the trachea). (2) Co poisoning, ........," The author states that mild degrees of hypoxia induce only in-attentiveness, impaired judgment, and motor in coordination and have no lasting effects. With severe hypoxia or anoxia, as occurs with cardiac arrest, consciousness is lost within seconds, but recovery will be complete if breathing, oxygenation of blood, and cardiac action are restored within 3 to 5 min. If anoxia persists beyond this time, serious and permanent injury to the brain results, particularly to those parts with marginal efficiency of their circulation. Clinically, it is difficult to judge the precise degree of hypoxia since slight heart action or an imperceptible blood pressure may serve to maintain the circulation to some extent. Hence some individuals have made in excellent recovery after cerebral anoxia that allegedly lasted 8 to 10 min or longer. An important clinical rule is that degrees of hypoxia which at no time abolish consciousness rarely if ever cause permanent damage to the nervous system". Regarding treatment, the author says that the treatment of anoxic encephalopathy is directed mainly at the prevention of a critical degree of hypoxic injury. After a clear airway is secured, artificial respiration, external thoracic cardiac massage, open-chest surgery, and the use of a cardiac defibrillator or pacemaker all have their place and every second counts in their prompt utilization. Once cardiac and pulmonary function are restored, there is some evidence that reducing cerebral metabolic requirements by continuous hypothermia for 48 to 72h may prevent the delayed worsening referred to above. Oxygen may be of value during the first hours, etc.
14. The main contention of the OPs, on the other hand, apart from preliminary objections discussed below, is that the hospital as also the involved doctors have very high reputation and substantial experience in handling all kind of medical conditions, surgeries and are equipped to deal with the emergencies which may arise during the course of treatment or surgeries. It is pointed out that the hospital is a multi-speciality hospital having ultra-modern operation theatre equipped with all the necessary monitoring systems and continuous provisions of oxygen and other material which might become necessary. As per the OPs, the Fenestration Discectomy L4/L5 right surgery was uneventful and the patient was duly monitored and there was no anaesthetic adverse event till the surgery was complete. However, after the surgery the patient, who was in prone condition, was brought into supine condition and the prescribed anaesthesia reversal protocol was followed which included administration of Myopyrolate drug. The patient developed ventricular tachycardia and did not show signs of recovery and had gone into cerebral death due to cerebral hypoxia. There is no doubt that OPs made all attempts to restore the hypoxic state but they failed as it was too late. A patient will suffer a cerebral death if the oxygen supply to the brain is not adequate for more than 3-4 minutes and it is irreversible and this is what exactly happened in the present case. As can be seen from the statement of objections filed by OPs 1-4 which more or less emphasize the same version which primarily is based on treatment/discharge summary provided to the complainant, the surgery of the patient was completed uneventfully and successfully and the patient was put back from prone to supine position with intact continuous monitoring and 100% oxygen supply. Her oxygen and BP levels were monitored and were normal. Once the patient started having spontaneous respiratory breathing, reversal drug to neuro muscular blockade was given. After 1 or 2 minutes, it was noted that there was dysrhythmia i.e. abnormal/irregular heartbeat which showed up as Ventricular Tachycardia. Immediately, the patient was shifted to Intensive Care Unit (ICU) and was injected with injections for treating the same. It is very clear that the patient went into a condition called Ventricular Tachycardia at the time when the reversal drug, to bring the patient back from the effect of anaesthesia, was given. It is a well-established practice and medical necessity to give a reversal drug to get the patient out of anaesthesia. Ventricular Tachycardia is a condition that may occur when the reversal drug is administered. When anaesthesia with muscle relaxant is given, the patient goes into what is called a neuromuscular blockade and to reverse the said situation the reversal drug needs to be given. The reversal drug may cause the condition called Ventricular Tachycardia, which fact can be verified from the Indian Journal on Anaesthesia and various other medical research papers filed. Even in the Sota Omoigui's Handbook on Anaesthesia drugs, it is stated that one of the adverse reactions of the reversal drug is Ventricular Tachycardia. Reversal drug has to be administered to the patient to recover the patient from the effect of anaesthesia. The non-administering of the reversal drug would jeopardise the patient's life. Therefore, in the present case the medical condition suffered by Smt. Shailja is unfortunate but has occurred in spite of the best treatment given to her. From the Anaesthetic Chart of the patient as provided by OP 4, it is clear that general anaesthesia was given and patient was ventilated with O2 continuously throughout the surgery and during recovery phase. Patient was monitored with ECG, O2 saturation, BP and ET CO2 throughout the surgery. OP 1 and 2 admittedly housed the patient Smt. Shailja for a period of about 15 months and have not compromised with the best possible care and facility available with them. OP 1 hospital also invited Dr. Venkata Ramana, Neuro Surgeon at their own cost to examine the patient only to ensure the best care and treatment for the patient. The complaint, which has bald averments of negligence by OPs is bereft of any credible evidence or any expert evidence or any support in any medical literature. The OPs filed medical literature supporting the averment that administration of myopyrolate can trigger complications of tachycardia which in turn can result into hypoxia. OPs also filed and relied on Supreme Court decisions supporting the averments that onus to establish the negligence is on the complainant, every unfortunate complication during surgery cannot be attributed to medical professional's negligence, there is no liability for error of judgment by a professional and that no more than ordinary skill and ordinary care can be expected from medical experts. OPs have followed all prescribed protocols, there is no evidence of violation of any prescribed standard, treatment or protocol or of negligence and hence complaint is without merits.
15. We have carefully and patiently heard the counsels for the parties and minutely perused the evidence brought on record. First, the preliminary objections raised by the OPs may be dealt with. The first objection is that complaint is barred by limitation. This contention has been disposed of by this Commission vide its order dated 25.04.2018 wherein it has been observed that the patient Ms. Shailja is in a continuous vegetative state and therefore, the cause of action is a continuous cause of action. Apart from this, the complaint has been filed on 16.05.2013 which is within two years after the Writ Petition before the Karnataka High Court was dismissed on 16.08.2011. Therefore, the objection with regard to the limitation has no merit. Other preliminary objection raised by the OPs is that the complaint is vexatious and an abuse of process of law because the complainant has been simultaneously pursuing various remedies by way of filing complaints before the police/Magistrate, with Karnataka Medical Council and with Government Authorities. In this behalf we have to observe that the remedy before this Commission is in addition to, and not in derogation of, other remedies which the complainant may pursue as per law. On that ground an otherwise meritorious complaint cannot be branded as vexatious. Next preliminary objection is that the complaint involves complicated questions of facts and lengthy medical testimony and therefore, the remedy by the complainant needs to be pursued before a civil court. This objection also does not appear to have any merit because not only a large number of cases involving allegation of medical negligence have been and are being dealt with and decided by this Commission, but also because this Commission has ample powers of a civil court which in appropriate cases can always be invoked by the parties and be exercised by the Commission. The last preliminary objection is with regard to the pecuniary jurisdiction. It has been stated that assuming without admitting that the compensation becomes payable to the complainant, the quantum of such compensation under no stretch of imagination can exceed Rs.1 crore and the compensation claimed in the complaint of Rs.1,86,48,189/- (subsequently enhanced in amended complaint) is exaggerated so as to unreasonably and unduly invoke the jurisdiction of this Commission. In this behalf, this Commission has already taken a view that as per section 21 (a) of the CP Act, 1986, the National Commission shall have jurisdiction to entertain a complaint where the value of goods or services and compensation, if any claimed, exceeds Rs.1 crore and that the merit or the rationale of the claim made in the complaint is not required to be gone into while deciding the issue of pecuniary jurisdiction. In view of this, there is no merit in any of the preliminary objections raised by the OPs and therefore we proceed to decide the complaint on merits.
16. Turning to the merits, the first allegation in the complaint is that the surgery itself was uncalled for and was not unavoidable and therefore, the consultant Orthopedist OP-3 was negligent in advising and undertaking the surgery when the same could have been avoided and that the informed consent after explaining likely serious complications was not obtained. There is no material supporting the contention that the advise for surgery itself was erroneous. The pre-surgery MRI report available on record evidences the ailment of the patient and necessity or advisability of surgery and therefore we find no force in the allegation of negligent advice for uncalled for surgery. Moreover, the consent of Ms. Shailja and compliant-1 for the surgery is also available on record.
17. The second and main allegation in the complaint is that the OPs 1 to 4 did not ensure during and after the surgery that oxygen-supply to the patient was not interrupted or stopped and such absence of basic critical care, caution and preparedness as can reasonably be expected jointly and individually from the OPs, and as can be taken to be the minimum required standard of skill and care expected of surgeon, anaesthesiologist and hospital, is a clear case of gross negligence on the part of the OPs. The complainant has primarily relied on the fact that a perfectly healthy young patient of 33 years, having no comorbidities, was taken to the OT and after 2.5 hours, came out and remained in vegetative state thereafter. Second reliance of the complainant is on the order of the Karnataka Medical Council, which has held OP-4 grossly negligent in duty, care and caution expected from anesthetist. There is no dispute that Ms. Shailja was taken to the operation theatre (OT) on 30.11.2009 and after the surgery and further chain of events which occurred and lasted for nearly 2½ hours, she was directly taken to the ICU where she was on ventilator for as many as 15 days thereafter and remained unconscious or in vegetative state throughout her stay in the hospital till 17.02.2011 when she was referred to and shifted to M.S. Ramaiah Hospital (OP 5) and even thereafter. Thus, the complainant is right that apparent and indisputable "event" which led to the vegetative condition (which in discharge summary dated 01.06.2011 has been stated by M.S. Ramaiah Hospital to be "hypoxic encephalopathy") has happened within the four corners of operation theatre and in the presence of and when being attended to by the surgeon Dr. Muthu (OP 3), Anaesthetist Dr. Kukreja (OP 4) and nursing and other assisting team members of the OP 1 hospital. The complainant requested the hospital authorities vide letter dated 29.05.2010 (page 43) to provide the "report regarding the surgery made to her, medicines suggested, the decisions taken by you to cure her from the present situation and the documents pertaining to action taken by you to cure her by giving advance treatment". The same was responded to by the hospital by providing a "treatment summary" on 14.06.2010. We also note that the OP hospital and the OPs 3 and 4 have stated the chain of events in the operation theatre more or less in the same words basing it on this treatment summary and discharge summary. The treatment summary (supra) describes the critical event as "after the surgical procedure was completed successfully and patient was positioned in supine position, reversal of muscle relaxant was given. During recovery phase of anaesthesia, patient developed ventricular tachycardia with temporary or transient hypoxia and hypotension. ACLS protocol followed and resuscitated in OT............. first CT scan brain done on 01.12.2009 which showed cortical sulci are slightly effaced? mild edema. Subsequent CT scan brain done on 03.02.10, which showed Bilateral symmetrical old external capsule and periventricular (subependymal) region infarcis, Ischemic changes in both occipital and left high fronto-parietal region, mild dilated both lateral and 3rd ventricles and mild diffuse cerebral atrophy......" While the OP 1 provided the above summary after about 6 months from the date of the event, the supporting diagnostic basis for the above summary not only was not provided to the complainant, such reports have not been placed even before this Commission. Therefore, there is no indication as to how the discharge summary states that the patient had developed "ventricular tachycardia". In our opinion, the patient in an OT is on continuous monitoring and at least the print of the ECG report indicating or evidencing the occurrence and time of ventricular tachycardia as suggested in the discharge summary should have been firstly provided to the complainant and in any case should have been placed before this Commission. After receipt of this treatment summary, the complainant wrote a further letter dated 06.09.2010 and objected to the averment in the summary that there is limb movement or that she can be smoothly made to sit on the wheel chair. It appears that no copies of investigation or diagnostic reports were provided to the complainant along with treatment summary on 14.06.2010. Subsequently, the complainant made an application under RTI to the OP 1 hospital on 20.09.2011 asking for copies of a) all pre-operation test reports, b) primary case sheets, c) anaesthesia flow record chart, and d) case history report from 29.11.2009 to 26.11.2010. Such medical history as requested by the complainant for period of treatment of 362 days has been provided by the hospital which is again encapsulated in 13 pages (page 241 to 252). The only enclosures or further information by way of laboratory reports or CT scan report or any other diagnostic report or the details of medication/consultations given in the ICU and/or ward provided to the complainant is the pre-surgery lab investigation report dated 29.11.2009, clinical history of the patient on the day of the admission and anaesthetic report. No other information about the patient's condition or concurrent record of doctors'/nursing notes etc. was provided in response to RTI request. The discharge summary dated 26.11.2010 more or less reiterates what is stated in the treatment summary. The same also however, does not appear to have enclosed any diagnostic or investigation test reports or any other document which would directly or indirectly, explicitly or impliedly support the events narrated in discharge summary. No prints of CT scans or MRI, if any done, no record of nursing or progress notes or administration of medicines or of visits and examination by the professionals or information as to how patient's condition has progressed in the hospital, appears to have been provided to the complainant either suo-motu at the time of discharge or in response to RTI application. The complainant has, inter alia, filed these documents, as received by him, as the evidence to support the allegations. It is submitted on behalf of the complainant that the defence, including the stand taken in concocted and belatedly supplied "treatment summary" and "discharge summary" is not at all credible and is simply devised and designed to wriggle out from the liability of palpable negligence evident by the pre and post-surgery state of the patient. The defence that the oxygen flow and the securing of airway including the position of the airway tube was duly monitored and it was only the administration of anaesthesia-reversal drug Myopyrolate which induced the side effect/reaction of ventricular tachycardia is not supported by any evidence and is contrary to the testimony given by OP 4 Dr. Kukreja before the Karnataka Medical Council and is also contrary to the medical literature on the risks of anaesthesia. As per the complainant, as a matter of fact, it is the reduced oxygen supply which would induce tachycardia. The reduction or stoppage of oxygen supply to the patient must have been completely and negligently overlooked by the OPs 3 and 4 who were present in the operation theatre along with all the nursing staff who are expected to have taken due precaution and care in this regard. Such reduction/stoppage of oxygen supply must have happened on account of one of the reasons namely, (i) non-inserting of endotracheal tube in proper way, (ii) over dosage of anaesthesia (iii) slipping of endotracheal tube or (iv) biting of the endotracheal tube by the patient. For supporting the contention, the complainant has relied on the clear-cut finding of the Karnataka Medical Council in their order dated 22.08.2013 that during the shifting of the patient from prone to supine position, the endotracheal tube might have slipped or the patient might have bitten the same, leading to failure of supply of oxygen to brain resulting in cerebral death. The arguments presented by OPs 1-4 to the effect that in fact the patient first developed tachycardia consequent to administration of Myopyrolate drug which resulted into transient/temporary hypoxia was not accepted by the Karnataka Medical Council. As reproduced above, OP 4 was held guilty of failure in performing the duty required of an Anaesthetist and "has failed to perform his duty and allowed the patient to go into cerebral hypoxia. The gold 3-4 minutes were lost resulting in cerebral death." The OP however has relied on Medical Council of India's decision dated 31.07.2020 in appeal filed by the OP 3 and 4 wherein the Medical Council of India (MCI) has, reversed the decision of the Karnataka Medical Council and exonerated thereby the OP 4 from the finding of negligence.
18. While the complainant has maintained that no notice by the Medical Council of India was received by him and that the presence of advocate Mrs. Farhat Jahan Rehmani has also been wrongly recorded by the Medical Council of India, that aside, we have noted that the MCI has relied exclusively on the documents containing the version of OPs 1 to 4 as recorded in the discharge summary. While doing so, the MCI has not categorically mentioned any other documents relied upon by it and the contents thereof and the inferences drawn therefrom. The MCI has also not dealt with the observation of the Karnataka Medical Council to the effect that the cerebral death has occurred due to hypoxia and that golden 3 to 4 minutes have been lost implying that there was lack of constant vigil on the vital parameters during and after the surgery. The finding of KMC that the OP 4 failed in his duty and "allowed the patient to go into cerebral hypoxia" does not appear to have been effectively repelled on sound basis by the MCI. The fact that "cerebral death", as noted by KMC, could not have occurred unless the oxygen supply completely stopped for more than 3 to 4 minutes during which period the doctors and nursing staff in the OT have been completely negligent in monitoring the parameters, has not at all been taken note of by the MCI. We have also perused the Medical Article referred to by the Ethics Committee and have noted that the same is a case study of an 18 month old child who suffered immediate cardiac arrest consequent to administration of neostigmine. It is not clear as to how the MCI reversed the findings of the Karnataka Medical Council on the basis of a case study which concludes that "Neostigmine must be cautiously administered in order to reverse neuromuscular blockage; especially in children whose parasympathetic system is not fully developed. Furthermore, especially in paediatric cases, atropine must be administered first to increase the heart rate, after which neostigmine can be administered more safely". In view of this, we are of the considered view that the conclusion arrived at by the Karnataka Medical Council to the effect that it is the gross negligence of the OP-4 which led to "cerebral death" of Ms. Shailja stands on a footing sounder than the view of the MCI and we are therefore inclined to treat the same as a strong evidence against the OP-4 and vicariously against OP-1, which they were required to refute by way of material contemporaneous and independent evidence. Therefore we hold that because the event occurred behind the closed doors of the OT and within the special and expert knowledge of OP1-4, the burden of establishing that the events as stated in the discharge summary in fact took place, and to establish what prescribed protocols to meet the exigency of hypoxia and/or tachycardia were followed, was indisputably on the OPs 1-4, particularly so because KMC had already held against the OP-4 when the complaint was filed.
19. On the other hand, we have noted that there is a complete blackout as to what exactly transpired in the operation theatre, what is the diagnostic contemporaneous evidence of such event(s), how they were handled and what is the diagnostic or monitoring evidence for such steps, if at all taken. The fact that "cerebral death" does not result unless the brain is completely and fully deprived of oxygen supply at least for a continuous period of 3 to 4 minutes, is not only a common medical knowledge but has also been so recorded by the Karnataka Medical Council. We are of the view that OP-3 and OP-4 and attending staff of OP-1 were required to meticulously record the events, test reports, medical advice including vital parameters of the patient, and OP-1 was required to ensure the same, which has not at all been done and evidence thereof is not at all brought on record by the OPs. There is no evidence of tachycardia. Moreover, whether even the alleged cardiac event of tachycardia can result into complete stoppage of oxygen supply to the brain for a continuous long duration of more than 3 to 4 minutes and whether in such an eventuality the operation theatre is not required to be equipped to artificially ensure by mechanical or other modern methods to adequately oxygenate the brain immediately, so as to minimise the damage to the brain, has also not been demonstrated before us by the OPs. The OPs have deliberately withheld not only from the complainant but also from KMC, MCI and from this Commission even the basic necessary information in the form of nursing notes and daily doctor advice notes about the treatment and the diagnostic tests which were conducted even after the patient was shifted to the ICU. Also though it may be possible that the onset of alleged tachycardia could have been noticed by the anaesthetist on the cardiac monitor in OT, the diagnostic evidence of how the same resulted into complete stoppage of oxygen supply to brain for 3-4 minutes and how the same could not be noticed or treated by the anaesthetist, has not come on record and has remained suspicious. The cardiac events are bound to have its traces and trail in the post-event treatment documents and further diagnostic test results. The withholding of such vital and critical documents would tend to establish that the veracity of the version of the OPs with regard to the occurrence of tachycardia and consequent hypoxia is doubtful. Therefore, the complainant is absolutely right in submitting that because the inexplicable, incomprehensible and unlikely events as alleged suggested by OPs happened within a short period of two hours under the care and treatment and within the special and expert knowledge of OPs 1-4, the onus of explaining the same and of establishing the chain of events of monitoring of airway-tube and oxygen-supply, and of occurrence of tachycardia leading to hypoxia as suggested by them was on them which has not at all been discharged by OPs 1-4. Therefore, question of discharging further onus to establish that the same were handled and treated (i) with due expediency (ii) as per prescribed protocols and (iii) while providing enough and proper artificial support through requisite medical equipments, does not arise at all because even the first burden of establishing the chain of events through cogent independent contemporaneous evidence itself has not at all been satisfactorily discharged by the OPs. Mere description of events in the discharge summary by the OPs, and adopting the same version in reply to the complaint, without any cogent and contemporary independent medical evidence, would not suffice.
20. We are absolutely conscious of the fact that medical professionals are expected to have and to exercise skill, caution and preparedness to anticipate and meet exigencies no more than an ordinary expert in the field. They cannot be held negligent simply of error of judgment or because complications arose which led to unfortunate outcomes. However, every professional certainly owes a duty of preparedness for and skillful handling of the likely emergency or eventuality also. In any case, an honest version of and an exhaustive account of what exactly transpired during and after the surgery including the supporting results of the diagnostic tests and the measure of vital parameters and treatments of the ailments and emergent events should in any case is required to be provided to the patient or their relatives within reasonable time and a transparent record should have been produced before us for discharging the onus. Record of such events, diagnostic tests, consultations, doctors' recommendations and administration of treatment from time to time ('bed-head notes') in the form of detailed, daily and chronological record is natural in a hospital set up and is required to be maintained and supplied to the patient. The ECG prints/reports or blood reports or ventilator notes or other independent and contemporaneous evidence establishing the occurrence of tachycardia is not produced by OPs. Similar evidence or detailed notes of step-by-step treatments and equipment support provided inside the OT is also not produced by the OPs. What has been supplied to the complainant and what is produced before us is a conveniently prepared sketchy record of the post-facto noting of the doctors describing the events in the OT, which is not corroborated by any primary and independent record. of vital parameters and test-reports/ECG. In view of this, we are of the considered opinion that the fact that the young and healthy patient suffered a "cerebral death" inside the operation theatre in itself is a prima facie evidence of lack of due care and caution on the part of OPs 1 to 4. The same was compounded by maintaining and providing less than bare minimum necessary record establishing "what, why and how it happened and how it was treated". No credible independent evidence has been placed by the OPs before us. The treatment summary provided to the complainant on 14.06.2010 though records the result of the CT scan of the brain in medical terms like "periventricular region infrasis" and "ischemic changes in high fronto-parieatal region" it has avoided providing the supporting reports. Therefore, though the reversal drug can, and may in some cases, result into tachycardia, it has not been established by the OPs that it did happen to Ms Shylja. It was the burden of OPs to establish that the chain of events leading to cerebral death of the patient was in fact triggered by any complication like tachycardia. An adverse inference against OPs is called for because the OPs have voluntarily and actively attempted to withhold the best evidence in the form of requisite documents when the burden to establish that all reasonable and necessary preparedness and following of the required protocols to meet the emergency or exigency as can reasonable be foreseen, have been followed, was clearly on the OPs. Therefore we, on the basis of preponderance of probability and on the basis of evidence of the course of investigation and treatment produced and withheld by the OPs, are of the opinion that the patient did not suffer from or underwent any tachycardia due to myopyrolate but underwent hypoxia due to negligent and callous carelessness of OPs in monitoring and maintaining oxygen supply and in ensuring proper placement of endotracheal tube. Similarly, on the basis of diagnostic and treatment evidence which must have been maintained and be available with the OPs, but which has been withheld, we are also of the considered opinion that even if tachycardia did in fact occur, the same is not demonstrated before us to have been effectively and as per prescribed protocol handled and treated because the complete stoppage of oxygen supply to brain for a long duration of 3-4 minutes in cases of tachycardia is neither shown through literature to be a likely consequence of tachycardia nor is it shown as to how once disruption to oxygen supply was noticed, the same was handled either through medication or through appropriate medical devices. On the other hand, as has been noted by the Karnataka Medical Council, the slipping of the endotracheal tube or the biting of the same must have remained unnoticed. The OP 4 (Dr. Kukreja) in his cross examination before Karnataka Medical Council has categorically mentioned that ventricular tachycardia was noticed by him at the point of time of changing the patient from prone to supine condition. The reversal drug as per the summary sheet was administered after the patient was brought in the supine condition. Therefore, also it is more likely that the patient, at the time when she was brought to supine condition, was already undergoing hypoxia due to carelessness of OPs which was then showing up as tachycardia Perhaps the slipped endotracheal tube took more than 4-5 minutes before it got properly replaced and became of effective breathing assistance to the patient, and in the meantime, the patient had already suffered cerebral death. Be that as it may, the fact that the OPs have preferred to withhold the critical and contemporaneous evidence and have failed in discharging the onus in establishing that the unfortunate occurrence of cerebral death of the patient is despite and even after exercising due skill and caution in taking all necessary steps and in following prescribed protocols, we are, in consonance with KMC, constrained to hold that OPs are liable for the negligence and deficient service which has resulted into the vegetative state of the patient. We also conclude on preponderance of probabilities that the hypoxia suffered by the patient remained unnoticed and requisite emergency equipment support could therefore only be belatedly provided because a 3-4 minutes long complete absence of oxygen supply to brain remains wholly unexplained. We may note that while reserving the order for judgment, liberty was granted to the OP 1 and 2 to file "Xerox copies of the papers relating to the treatment in the hospital during the relevant period". The OPs filed compilation of 14 pages of which only pages 1 to 3 and 12, 13 purport to be the treatment record that too only for 30.11.2009 and 01.12.2009. Notably, the typed copies have not been provided nor the details of the suggestion for or findings of any diagnostic blood test or ECG report, etc. have been provided. No further record of treatment, diagnosis or advice have also been provided. We do not find that this record, filed after a gap of nearly 10 years of filing the complaint, has any credibility or is in fact a contemporaneous and exhaustive record of what transpired on 30.11.2009. For these reasons, we have not found any of these papers credible enough to find our favour.
21. The OPs have filed on record the medical literature bringing out that administration of anaesthesia reversal drug may result into tachycardia and the patient may consequently suffer damage to brain (page 5 to 8 of the written arguments). Article in annexure A1 mentions that marked hemodynamic changes are frequent in the course of ventricular tachycardia with systemic arterial hypotension, a decrease in cardiac output and evidence of cerebral, coronary and renal vascular insufficiency. Annexure 2, similarly states that such tachycardia is regarded as more serious arrhythmia because there is no booster action from atrial transport, with additional factor that muscle contraction originating in the ventricle may be less efficient than coordinated contraction via the Purkinje fibers. Investigation of sustained VT, induced during electrophysiological stimulation studies, have been carried out by several groups. Article at annexure 3 brings out the serious impact of ventricular tachycardia, which is described as a rhythm faster than 100 beats per minute. The ventricular tachycardia can be classified as sustained or non-sustained. The non-sustained tachycardia has generally accepted cut-off of 30 seconds. Sustained ventricular tachycardia may lead to hemodynamic collapse and consequently such patients require urgent conversion to sinus rhythm. Unstable patients have signs or symptoms of insufficient oxygen delivery to vital organs which may get manifested by hypotension, altered level of consciousness and dyspnoea. Article at annexure 4 describes ventricular tachycardia as potentially life threatened and responsible for sudden cardiac death in the United States. Sustained VT (i.e. which lasts more than 30 seconds) requires intervention within 30 seconds due to hemodynamic compromise. Rapid ventricular rate in VT leads to low cardiac output due to significant reduction in preload as well as stroke value. In the presence of disease, and left ventricular systolic dysfunction the hemodynamic changes mainly to systemic hypertension coronary answerable cerebral hypo perfusion syncope and even cardiac arrest. Coronary hypo perfusion further impairs hemodynamic, leading to ventricular fibrillation and even sudden cardiac death. Having minutely perused these articles, while we do appreciate the seriousness of the tachycardia once it has occurred, we are unable to locate in these articles even a single pointer of medical probability that the tachycardia could result into complete hypoxia for a prolonged period of more than 4-5 minutes to lead to cerebral death, particularly when even as per the version of the OPs, the VT was effectively tackled and "sinus rhythm" was soon achieved. In any case, as a matter of fact, tachycardia, whether sustained or non-sustained, would definitely show up either on the ECG monitor of which the data are either printed or retained in the digital format, or in Blood Gas or other subsequent reports. No such evidence has been brought on record by the OPs. Further, there is no evidence to establish that tachycardia first occurred which subsequently led to hypoxia for a long duration exceeding 4-5 minutes. Therefore, opinions expressed in these articles, on facts, in our considered view, are irrelevant.
22. The OPs have relied on the following decisions to contend that every unfortunate outcome in a surgery or treatment cannot be argued or held to be negligence or deficient service on the part of the treating doctors or hospital:
Jacob Mathew Vs. State of Punjab (2005) 6 SCC 1
18. ................ 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 possess the highest level of expertise in that branch which he practises. A highly skilled professional may be possessed of better qualities, but that cannot be made the basis or the yardstick for judging the performance of the professional proceeded against on indictment of negligence."
(b) Dr. Harish Kumar Khurana Vs. Joginder Singh (2021) 10 SCC 291
11. .......However, in unfortunate cases, though death may occur and if it is alleged to be due to medical negligence and a claim in that regard is made, it is necessary that sufficient material or medical evidence should be available before the adjudicating authority to arrive at a conclusion.
(c) Bombay Hospital & Medical Research Centre Vs. Asha Jaiswal & Ors.
2021 SCC Online SC 1149
34. Recently, this Court in a judgment in Harish Kumar Khurana v. Joginder Singh [Harish Kumar Khurana v. Joginder Singh, (2021) 10 SCC 291 : (2022) 1 SCC (Civ) 215] held that hospital and the doctors are required to exercise sufficient care in treating the patient in all circumstances. However, in an unfortunate case, death may occur. It is necessary that sufficient material or medical evidence should be available before the adjudicating authority to arrive at the conclusion that death is due to medical negligence. Every death of a patient cannot on the face of it be considered to be medical negligence..............
35. ..................The doctors are expected to take reasonable care but none of the professionals can assure that the patient would overcome the surgical procedures. Dr Kripalani has been attributed to have informed the complainant that the patient's legs were not working but Dr Kripalani denied all the averments by filing of an affidavit.
Kusum Sharma Vs. Batra Hospital & Medical Research Centre (2010) 3 SCC 480
89. On scrutiny of the leading cases of medical negligence both in our country and other countries specially the United Kingdom, some basic principles emerge in dealing with the cases of medical negligence. While deciding whether the medical professional is guilty of medical negligence following well-known principles must be kept in view:
I. Negligence is the breach of a duty exercised by omission to do something which a reasonable 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.
II. Negligence is an essential ingredient of the offence. The negligence to be established by the prosecution must be culpable or gross and not the negligence merely based upon an error of judgment.
III. The medical professional is expected to bring 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.
IV. A medical practitioner would be liable only where his conduct fell below that of the standards of a reasonably competent practitioner in his field.
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.
VIII. It would not be conducive to the efficiency of the medical profession if no doctor could administer medicine without a halter round his neck.
IX. It is our bounden duty and obligation of the civil society to ensure that the medical professionals are not unnecessarily harassed or humiliated so that they can perform their professional duties without fear and apprehension.
X. The medical practitioners at times also have to be saved from such a class of complainants who use criminal process as a tool for pressurising the medical professionals/hospitals, particularly private hospitals or clinics for extracting uncalled for compensation. Such malicious proceedings deserve to be discarded against the medical practitioners.
XI. The medical professionals are entitled to get protection so long as they perform their duties with reasonable skill and competence and in the interest of the patients. The interest and welfare of the patients have to be paramount for the medical professionals.
(f) Chanda Rani Akhouri Vs. M.A. Methusethupati (2022) SCC Online SC 481
27. It clearly emerges from the exposition of law that a medical practitioner is 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 to another. In the practice of medicine, there could be varying approaches of treatment. There could be a genuine difference of opinion. However, while adopting a course of treatment, the duty cast upon the medical practitioner is that he must ensure that the medical protocol being followed by him is to the best of his skill and with competence at his command. At the given time, medical practitioner would be liable only where his conduct fell below that of the standards of a reasonably competent practitioner in his field.
23. We have very carefully gone through these decisions and the mandate of the apex court therein. The OPs are absolutely right in contending on the strength of these decisions that neither the mere unfortunate outcome nor every error of judgment can lead to the inference of negligence of the treating doctor or hospital. Similarly, the negligence has necessarily to be established positively by reference to the duty cast on the professional and a breach thereof. However, in our considered opinion, this would not imply that the Hospital and the treating doctors are entitled not to maintain or not to provide to the complainant the requisite basic record of advise, treatment and diagnostic reports, and not file such best evidence before this commission and then to rely on absence of such evidence to plead that there is no evidence on record establishing the negligence. There is already evidence of an expert body KMC who have held the OP-4 guilty of medical negligence. It was therefore for the OPs 1-4 to establish the chain of events and exercise of due care and caution in OT through cogent and contemporaneous medical evidence, in which OP-1 to 4 have patently failed.
24. The OP 4 has also filed expert evidence of Dr. Sukumaran, consultant Anaesthesiologist by way of affidavit. He, after narrating the events in the operation theatre as recorded in the treatment summary, has stated that the proper care and caution has been exercised and due protocol has been followed by Dr. Kukreja while dealing with the unfortunate eventuality of tachycardia after administration of reversal drug. Along with the affidavit, the expert has enclosed Chapter 18 of the Clinical Anaesthesia Procedure of the Massachusetts General Hospital to support the averment that under anaesthesia ventricular dysrhythmias frequently occur during states of catecholamine excess, hypoxia or hypercarbia. We have noted the testimony. While indeed it is an expert testimony, the same however only highlights the fact that tachycardia during anaesthesia may occur if simultaneously accompanied by catecholamine excess, hypoxia or hypercarbia. We note that it is the hypoxia which perhaps as per Chapter 18 suggested by Dr. Sukumaran which can lead to tachycardia. Therefore, we are not very sure as to in which way the testimony of Dr. Sukumaran or Chapter 18 supports the contentions of the OPs. Moreover, it has also been recorded on page number 101 (page 3 of Chapter 18) of the compilation, under the heading III "Dysrhythmias", that unless there is a severe underlying heart disease, the hemodynamic changes consequent to the dysrhythmias are minimal. The etiology of such dysrhythmias is also stated to be hypoxia. In our opinion, Chapter 18 and the testimony of Dr. Sukumaran therefore in no way assists the OPs, particularly so because there is no credible evidence of occurrence of tachycardia leading to hypoxia in the first place.
25. The OP 5 and 6 have filed their objections to the complaint. Vide para 1 to 3 of the written version OP 5 and 6 have stated that complainants can have no grievance against OP 5 and 6 because the allegations and averments made in the complaint do not constitute any cause of action against OP 5 and 6. Admittedly, when the patient Smt. Shailja was brought to the OP 6 hospital, she was already diagnosed with Hypoxic Encephalopathy in OP 1 hospital. When she was brought to the OP 6 hospital on 17.02.2011, she had already suffered severe damage to the brain and she needed only nursing care and neuro-rehabilitation. On her admission, she did not obey commands and there was rigidity in all four limbs. She was properly provided requisite and possible neuro-rehabilitation and nursing. Because of sever neurological deficits she had already suffered before her admission in OP 6 hospital, she did not show any improvement in OP 6 hospital, and therefore, she was advised to be discharged and was accordingly discharged. There was no negligence or inappropriate treatment in OP 6 hospital. Therefore, the case against the OP 5 and 6 needs to be dismissed with cost. After carefully considering the evidence on record, we agree with the submissions of OP 5 and 6 that there is indeed no negligence or deficiency in service on their part as they entered the scene only after the patient had suffered an irreversible damage to the brain and after providing necessary medical assistance to their best possible extent, they advised for discharge. Therefore there is no valid grievance or cause of action against OP-5 and OP-6 and therefore complaint qua OP-5 and OP-6 is dismissed.
26. In conclusion, we firstly hold that the fact that a perfectly healthy lady of 33 years having absolutely no comorbidities is taken to the operation theatre and after remaining under expert and professional care of OPs 1 to 4 for about two hours, she has come out in an unconscious and vegetative state of "cerebral death" or "hypoxic encephalopathy", which doesn't happen unless the oxygen supply to brain is shut off completely for 3-4 minutes, is prima facie an inexplicable outcome which was required to be explained cogently by OPs, which has not been done. We hold secondly that because the facts and events inside the OT are under special and expert knowledge of the OPs 1 to 4, the onus is on them to duly and cogently explain the chain of events which took place within the close doors of the operation theatre and to establish the same with contemporaneous medical evidence. The contemporaneous medical evidence in the form of ECG reports, CT scan reports, Blood reports, ABG reports, etc., must exist in the normal circumstances, which have been withheld by the OPs from the complainant as also from this Commission. In view of this we hold that there is an active withholding of relevant evidences by the OPs. Consequently, we hold that the onus of explaining and establishing the chain of events as canvassed by them has not been discharged by OPs 1 to 4. Therefore, we have no hesitation in concluding that vegetative state of the patient is attributable to the insufficient precaution and care on the part of the OPs 1 to 4. In the absence of evidence of tachycardia, we are constrained to conclude that it is the obstruction of the airway (slipping or biting of endotracheal tube) or disruption in the oxygen supply or in respiration which started the unfortunate mishap leading to the hypoxia and the ultimate irreversible damage to the brain. We agree with the observations of the Karnataka Medical Council that primarily OP 4 has failed in exhibiting due care, caution and presence of mind in timely noticing the stopped supply of air/oxygen to the patient and in skillfully and expeditiously setting it right as per prescribed protocols. Thus, it is the negligent failure of the OP 4, who is trained in the area and whose duty it was to constantly monitor the vital parameters including continuous and sufficient supply of oxygen and to take quick corrective measures, if required, which resulted into diminished and completely stopped oxygen supply to the patient which has led to "hypoxic encephalopathy" or "cerebral death". If tachycardia in fact led to the complete stoppage of oxygen supply to the brain, it would have been a gradual and progressive reduction of blood saturation levels and subsequent improvement therein when the patient has finally attained normal parameters which could have easily been demonstrated documentarily before us by OPs by way of medical test/ECG/ABG reports which has not been done by OPs 1 to 4. The medical professionals and hospitals have obligation to maintain and supply to the patients the transparent, complete and correct record of all the events, procedures and treatments availed by the patients. Similarly, they have an obligation to explain with due evidence, the inexplicable events both to the patients as also to this Commission when allegation of medical negligence is raised. It is not sufficient for OPs, in such circumstance, to merely indicate through literature the likelihood of of a complication, but it would be incumbent on them to have maintained and produced the evidence that such complication did in fact arise. In view of this, we agree with Karnataka Medical Council's opinion dated 22.08.2013 and rely on Kerala High Court judgment in Dr. M.K. Gourikutty and etc. Vs. M.K. Raghavan & Ors. AIR 2001 Ker 398 supra decided on 08.08.2001. Accordingly, we hold OP 4 guilty of medical negligence and hold OP 1 vicariously liable for the irreversible brain damage and consequent vegetative condition of the complainant. The liability shall be joint and several.
27. Now we turn to the quantum of compensation to be awarded. Hon'ble Supreme Court in National Insurance Co. Ltd. Vs. Pranay Sethi (2017) 16 SCC 680 has laid down the principles to be followed for awarding compensation under the Motor Vehicles Act, 1988. While doing so, Supreme Court has further directed that the court shall be guided by paras 30 to 32 of the decision in Sarla Verma Vs. DTC (2009) 6 SCC 121. This Commission has been consistently applying these guidelines issued by the Supreme Court in computing the compensation to be awarded in the cases of medical negligence also. It is noted that the age of Ms. Shailja, the victim of the negligence of the OP 1 and OP 4, at the time of filing of the complaint, was 35 years. Ms. Shailja has been bed-ridden, in vegetative state and has suffered cerebral death. Apart from the loss of income of the patient and loss of active love, affection and warmth by the husband and the two children (the three complainants in this complaint), the complainants have additionally incurred the constant agony and pain of continuously witnessing the suffering of wife/mother. The complainants have to emotionally and financially invest in the care and treatment of Ms. Shailja. Because of the bed-ridden state of Ms. Shailja, she would require continuous enhanced medical care and treatment. The complainant has originally sought compensation under as many as 19 heads totalling to Rs.1,86,48,819/-, which subsequently in amended complaint was enhanced to Rs.7,85,48,189/-. However, we are of the considered opinion that in light of Supreme Court decisions supra, the compensation, apart from the loss of income and of medical and other expenses necessarily necessitated on account of the condition resulting from the negligence of the OPs, no compensation under any other head can be awarded.
28. Though the loss of income of Ms. Shailja to the tune of Rs.30 lakhs has been claimed in the complaint, no details or evidence thereof has been provided by the complainant. Ms. Shailja is a science graduate and has also done Masters in Arts. It is claimed by the complainant that she was running a nursery school in partnership with others. However, no evidence of income either of such partnership or of Ms. Shailja has been provided. Therefore, we would firstly need to estimate her income before the incident keeping her education in mind. Secondly, we would also need to estimate on a reasonable basis and to the best of our judgment, the future expenses to be incurred by the complainants. The expenses on the caregiving to Ms. Shailja as also to both the children on account of Ms. Shailja's inability to provide the same, would also need to be so estimated. No further loss of income/expenses including that for investment of time by the husband for looking after the children need to be awarded. In our considered opinion, the following estimates of such monthly expenses/income are fair, just and reasonable :
Monthly income of Ms. Shailja in November, 2009 Rs.20,000/-
Monthly income after applying 40% for future prospect Rs.28,000/-
Monthly medical expenses of Ms. Shailja Rs.5,000/-
Monthly care expenses of Ms. Shailja Rs.5,000/-
Monthly care expenses of children Rs.6,000/-
TOTAL Monthly loss/damage Rs.44,000/-
Yearly total loss/damage Rs.5,28,000/-
29. The age of Ms. Shailja is 35 years as on the date of the complaint. The Supreme Court decision in Pranay Sethi and Sarla Verma (supra) would require applying the multiplier of 16 to the income. However, considering the nature of expenses and continuous damage being suffered by the complainants qua the other expenses/liability as tabulated above, we deem it appropriate to apply the multiplier to the whole of the yearly loss/damage suffered by the complainants. Accordingly, the loss/damage suffered by the complainants in monetary terms would be Rs.84,48,000/-. Apart from this, the constant emotional damage of helplessly witnessing the agony of Ms. Shailja, to which the complainants have been relegated to as a consequence of the negligence of the OPs can also not been wholly go uncompensated. As a lump sum, we estimate such damage at Rs.3 lakh for each of the complainant. Thus, the total compensation that we deem just, fair and appropriate in the circumstances, as rounded off, is Rs.95 lakhs.
ORDER In view of the aforesaid discussions, the complaint is partly allowed. OP 1 M/s Mallige Medical Centre Hospital and OP 4 Dr. Mahesh Kukreja are jointly and severally held liable for payment of compensation of Rs.95 lakhs along with interest at 6% from the date of filing of the complaint till the actual date of payment. The complainants shall also be entitled to costs of Rs.2 lac. The compliance shall be made within a period of three months.
..................................................J RAM SURAT RAM MAURYA PRESIDING MEMBER ............................................. BHARATKUMAR PANDYA MEMBER