State Consumer Disputes Redressal Commission
Leelamma Joseph vs M/S G.G. Hospital on 22 February, 2013
Daily Order
Kerala State Consumer Disputes Redressal Commission Vazhuthacaud,Thiruvananthapuram Complaint Case No. CC/05/10 1. Leelamma Joseph Saroya,Link Valley,Kusumagiri PO,Edachira Rd,Kakkanad,Kochi BEFORE: SRI.M.K.ABDULLA SONA PRESIDING MEMBER PRESENT: ORDER
KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION VAZHUTHACAUD, THIRUVANANTHAPURAM.
CC.10/2005
JUDGMENT DATED:22.02.2013
PRESENT:
SHRI.M.K. ABDULLA SONA : PRESIDING MEMBER
SMT.A. RADHA : MEMBER Mrs. Leelamma Joseph, W/o Mr. Joseph.J, Residing at Saroya, Link Valley- : COMPLAINANT Kusumagiri P.O, Edachira Road, Kakkanad, Kochi-682 030. (By Adv:Sri.S.Reghukumar) Vs. 1. M/s G.G. Hospital, Thiruvananthapuram-11. (By Adv: Sri. Amaravila P. Venugopalan Nair) 2. Dr. Valsamma Chacko, Senior Consultant in Obstetrics & Gynaecology, G.G. Hospital, Thiruvananthapuram. : OPPOSITE PARTIES 3. Add. R3 Dr. Sasikumar, Senior Urologist, G.G.Hospital, Thiruvananthapuram. Adv for R2 & R3 : Sri.K.Muraleedharan Nair) JUDGMENT SHRI.M.K. ABDULLA SONA : PRESIDING MEMBER
The complainant is a house wife at present residing at Ernakulam and the 1st opposite party is the hospital at which the complainant was subject to a surgery. The 2nd opposite party is the doctor who performed the surgery. The complications arose as a result of the negligence and deficiency in service of the opposite party No.2 in performing the initial surgery which was done on 18.9.2003 at the 1st opposite party's hospital. Later as per the version of the opposite party's, the additional 3rd opposite party was impleaded as per I.A.853/06 dated:31.10.2006 by the complainant. In short the complainant while she was staying with her husband in Mumbai, she was having some gynaecological problems during the year 2003 for which she consulted with Dr.Sreelatha Guptha a well known Gynaecologist in Mumbai in the month of August 2003 and that after routine tests, smear test and scan test the complainant suspected malignancy in the uterus and the complainant was doubtful about the findings. She decided to have a 2nd opinion and consulted with another Gynaecologist, Dr. S.P.Shinde who after conducting a biopsy test, advised her to undergo an immediate hysterectomy by an open abdominal surgery. As per the version of the complainant she and her husband decided to have the said operation done at Thiruvananthapuram where they had the hold and assistance of their close relatives. In the result she came to Thiruvananthapuram and consulted the 2nd opposite party doctor of the 1st opposite party hospital and thereafter going through the papers including the referral letter of Dr.Shinde, the 2nd opposite party doctor also agreed with the observations and swoothed the complainant saying that the abdominal hysterectomy was a comparatively simple operation and the required facilities were available in the 1st opposite party hospital. As per the instruction and advise of the 2nd opposite party doctor concerned she was admitted in the 1st opposite party's hospital on 17.9.2003 for an open abdominal hysterectomy and she was taken to the operation theatre by 8.30 am on 18.9.2003 for hysterectomy. It is alleged by the complainant that though she was taken to the theatre for the operation by 8.30 am, it was around 3.pm that the 2nd opposite party told the husband of the complainant that the operation had been very complicated since the bladder and uterus had been almost fused together and in separating them, the bladder has sustained injuries which had to be repaired and hence the complainant would be in the ICU till next morning. It is further alleged by the complainant that the 2nd opposite party had told the complainant's husband by 6 pm, that there had been no urine output and that the 2nd operation would be required. On the very same day by 8.pm her husband was required to arrange 2 units of blood for the purpose of conducting another operation. The complainant said that the additional 3rd opposite party also had participated in the operation, however by 6 am on 19.9.2003 the doctor told the complainant's husband that she had to be taken either to KIMS Hospital or the Medical College Hospital, Thiruvananthapuram and since the 2nd opposite party told that she was working at KIMS Hospital also, the complainant's husband opted for KIMS Hospital and accordingly the complainant was shifted to KIMS by 9 am on the very same day where the complainant was subjected to another operation for rectifying the urine blockage and the bladder damage. It is stated that the complainant had to be in the ICU for 5 days and even after the surgery there was a leakage of urine since the urine produced was flowing out totally unchecked and uninterrupted through day and night. Further stated that since the doctors in KIMS Hospital could not effectively do anything to manage the urine output, then she was taken to Jaslok Hospital in Mumbai where the leakage of urine was partially rectified by another operation and since the urine leakage could not be completely stopped, the complainant was taken to Dr.Rajamaheswary a Urogynaecoloigist in Chennai who with the aid of an implant had control the passage of urine. The doctor had imposed severe restrictions in the life of the complainant and also had stated that there was no assurance can be given regarding the functioning of the implant.
2. The complainant who alleged in the complaint that she had to undergo 5 major surgeries within a span of 140 days of hospitalization due to the negligence of the 2nd opposite party in conducting the Laparoscopically Assisted Vaginal Hysterectomy operation (LAVH) which was done without obtaining consent and when it was contraindicated without doing mandatory pre-operative tests. The complainant alleged that the 2nd opposite party had done substantial damage to the bladder and uterus of the complainant while conducting the operation and it is because of the said damage that the complainant had to undergo the subsequent operation even after which the complainant and her family are suffering from which she has claimed a compensation from the 1st and 2nd opposite party are jointly and severally liable to pay the compensation for the negligence and deficiency in service committed by them. The cause of action of the complaint arose on 16.9.2003 and the complainant consulted the 2nd opposite party who advised to go for the surgery TAH/BSO and on 17.9.2003 when the complainant was admitted to the 1st opposite party hospital at Thiruvananthapuram and on 18.9.2003 when the complainant was subjected to the surgery LAVH by the 2nd opposite party which resulted in drastic adverse consequences and on 19.9.2003 when the complainant was admitted to the KIMS Hospital at Thiruvananthapuram and was operated upon and on 26.1.2004 when the complainant was admitted to the Jaslok Hospital, Mumbai and on 28.1.2005 when the complainant was subjected to the treatment at Chennai and continuously thereafter and hence the Kerala State Consumer Disputes Redressal Commission has got the territorial jurisdiction to entertain the complaint.
3. Hence the complainant prays for the following reliefs:-
(a). To direct the opposite parties 1 and 2 to pay a compensation of Rs.50 lakhs under the head of the negligence and deficiency in service committed by the opposite parties.
(b) To direct the opposite parties 1 and 2 to pay a compensation of Rs.20 lakhs towards further cost of medication and treatment.
(c) To direct the opposite party to pay Rs.30 lakhs as cost of the proceedings.
(d) To grant such other reliefs which the complainant may ask for the cost of the proceedings of the complaint and which the Commission deems fit for the ends of justice. Hence the complaint.
4. The 2nd opposite party appeared after receiving the notice from the Commission and the additional 3rd opposite party was subsequently impleaded on the interim application filed by the complainant based on the pleadings in the written version filed by the 1st and 2nd opposite parties. The 3rd opposite party was impleaded as he had done some procedures as an emergency measure after initial surgery and for proper adjudication of the dispute he is a necessary party to the complaint.
5. The 1st and 2nd opposite parties contended in the version that there was no negligence or deficiency of service on the part of the 1st opposite party and that there was no employer and employee or master and servant relationship between the 1st and 2nd opposite party respectively. Another contention taken is that the complainant had opted for the treatment of the 2nd opposite party at the option of the complainant and that the 1st opposite party hospital had provided only the treatment facilities to the 2nd opposite party for consultation, clinical investigation and the patients who come for availing treatment or the specialist like the 2nd opposite party received treatment according to the judgment of the specialists utilizing the facility provided by the 1st opposite party. Raising the above, among other usual contentions the 1st opposite party prayed for the dismissal of the complaint. But the 2nd opposite party contended in her written version that the treatment was given by her to the complainant in the 1st opposite party's hospital but she has stated that it was given after detailed study of the histopathological report and reference records and also considering the health condition of the complainant/patient and she concluded that the complainant requires only a cone-biopsy and conservative management and followup treatment and informed the same to the complainant. But the complainant was adamant to undergo hysterectomy and also reluctant to undergo hysterectomy then she decided to conduct a LAVH and the very same was done under the consent of the complainant. Another contention raised by the complainant is that she has done the LAVH with the assistance of a senior Gynaecologist and the LAVH was uneventful though there was some difficulty in separating the uterus from the surrounding tissues included bladder. Further admitted that there was a leakage of blood stained urine and then alleged that bladder injury which is a common complication and as the leakage continued inspite of her best efforts to repair the injury, the assistance of the additional 3rd opposite party was called for who conducted a laparactomy. The 2nd opposite party doctor submitted that though the repairs were effected by herself and the Urologist and the additional 3rd opposite party, then the patient developed a condition of "anuria" and as the Urologist was not in station, another Urologist of another hospital was called for who advised to wait till next day and to restrict IV fluid. The 2nd opposite party doctor admitted that the complainant was transferred to KIMS Hospital on the next day only as per the will and option of the complainant and her husband where another surgery was performed and the complainant was in the ICU for 5 days. The doctor concerned admitted the surgery which has done in the KIMS Hospital, the urinary leakage could not be effectively controlled and hence undwelling, urinary catheter was put on the complainant and the complainant was discharged on 6.10.2003 with the advice of come back after two weeks. Another contention of the 2nd opposite party doctor is that during the review check up of the complainant, the arrangements were made so that the complainant was examined by a senior and well known Gynaecologist and as suggested by the said doctor the patient was advised to see Dr.Roy Chaly an eminent Urologist at Kozhikkode for better treatment and the complainant who was not willing to the same and treated the doctor, 2nd opposite party had no further information about the complainant thereafter. It is also contended that there was no negligence or deficiency in service on the part of the 2nd opposite party doctor and the complainant/patient was given proper care and treatment after the surgeries and it was with due diligence, caution and expertise that the LAVH and subsequent operations were conducted by the 2nd opposite party and as the complainant is ill motivated, the same is liable to be dismissed with cost.
6. But the very same time additional 3rd opposite party who impleaded later who already accepted the contentions raised by the 2nd opposite party and has further submitted that there was being unnecessarily impleaded in the complaint. According to him he had reached the operation theatre in pursuance to the emergency call for the hysterectomy operation by the 2nd opposite party and had exposed the bladder of the complainant and found that the tear was only partially sutured from below what he had stitched the rest of the tear except for the lower part ie the part that contained ureteric openings. It was also clearly admitted by the additional 3rd opposite party doctor that the complainant's condition was very critical and so he decided not to explore further and he instructed to evaluate ureteral entrapment later also. However the additional 3rd opposite party has also a case that since he had to leave the station on an urgent matter, the 2nd opposite party was informed of the need for further investigation and another Urologist can take charge of the situation. It also contended that there was absolutely no negligence or deficiency in service on the part of the 3rd opposite party doctor. Hence he prayed for dismissal of complaint with compensatory cost. In view of the fact that he is impleaded as 3rd opposite party unnecessarily and drag to the court.
7. The evidence consisted of the oral testimony of the complainant who was examined as PW1 and witnesses were examined as PW2 and PW3. From the part of the complainant she marked the documents Exts.P1 to P28. On the side of the opposite parties DW1 to DW5 were examined and marked Exts.B1 and B2. The case sheet from the KIMS Hospital was marked as Ext.X1.
8. Heard the learned counsel on respective sides in detail. Based on the facts, circumstances and evidence and provisions of law and evidence, the following issues arise for consideration:-
They are:-
1. Whether the complaint is maintainable as per law?
2. Whether there is negligence and deficiency in service as per the Consumer Protection Act on the part of the 2nd opposite party?
3. Whether there is any deficiency in service on the part of the additional 3rd opposite party as per the Consumer Protection Act?
4. Whether the 1st opposite party is vicariously liable for the acts of 2nd and 3rd opposite party?
5. Reliefs and costs?
9. Issue No.1 It is not in dispute that the complainant had availed the treatment of the 2nd opposite party at the 1st opposite party hospital. It is also seen that the treatment was imparted on payment of consideration and has been duly receipted by the 1st opposite party hospital. Though the learned counsel for the 1st and 3rd opposite parties argued that they are unnecessarily arrayed in the complaint, we have taken a view that the complainant had received the treatment in the 1st opposite party hospital and the fees were received by the 1st opposite party and the opposite parties 2 and 3 have been employed by 1st opposite party and hence the allegations to the contrary are rejected. It is also found that the 2nd opposite party has utilized the equipments and staff of the 1st opposite party and that the 1st opposite party has no contention that the 2nd opposite party was not in the list of doctors of the 1st opposite party hospital. The contention of the 3rd opposite party that he is not a necessary party cannot also be accepted on the ground that it is found that he is the Urologist of the 1st opposite party hospital and that he had conducted an emergency laparotomy after the LAVH was done by the 2nd opposite party. Hence on the issue of maintainability, it is found that the complaint is maintainable against the opposite parties. This issue is answered accordingly.
10. Issue Nos.2 to 5(a) The complainant has a case that it is because of the deficiency in service of the 2nd opposite party that she had to undergo 4 major surgeries subsequent to the surgery done by the 2nd opposite party. She has also alleged that even though the doctor at Mumbai had suggested for an open abdominal surgery, the 2nd opposite party had opted for Laparoscopically Assisted Vaginal Hysterectomy (LAVH) even without the consent of the complainant and even when doing the LAVH, the 2nd opposite party was careless and negligent. She alleged that the consent was taken only for doing TAH / BSO and that she was asked to get admitted for TAH / BSO. She has alleged that the contraindications for LAVH ought to have been considered by the 2nd opposite party and that proper blood test and other routine tests were not carried out by the 2nd opposite party before the surgery.
(b) The complainant has a still further case that when it was found that the situation of the patient went out of the control of the 2nd opposite party, she ought to have immediately referred the complainant to a better hospital and the delay in doing so had caused irreparable injury and hardships to the complainant. The competency, qualification and experience of the 2nd opposite party for doing LAVH is also questioned by the complainant apart from the allegation that the case records maintained by the opposite party did not contain the essential details for continuation of the treatment in the subsequent hospitals where the complainant was subjected to further operations and that vital materials were suppressed in the case sheet.
(c) The 2nd opposite party has defended the allegations contending that though she had suggested only conservative surgical procedure like cone biopsy and follow up treatment and it was the complainant who was adamant to undergo hysterectomy since they had come all the way from Mumbai for that specific purpose. The 2nd opposite party has also contended that the complications that arose consequent to LAVH, were common complications and necessary treatments were given to the complainant with due care and caution. The allegation that no consent was obtained from the complainant for LAVH has also been denied by the 2nd opposite party and it is contended that informed consent was obtained from the complainant and her husband before the operation and that on finding that there arose some complications, the assistance of the Urologist, the additional 3rd opposite party was called for who had done laparotomy for stitching the damaged bladder and necessary repairs for curing Urine leakage and on finding that the leakage could not be effectively controlled, the patient was transferred to KIMS Hospital where another surgery was done for rectifying the injury and its consequence. It is her very case that the complaint filed by the complainant before this commission is liable to be dismissed with costs as the same is frivolous and vexatious.
(d) On an analysis of the entire facts, evidence, circumstances and supporting arguments of the counsels for the respective sides, we find that the 2nd opposite party has no case that the complainant was not her patient or that she had not done the LAVH on the complainant. In the written version it is very specifically stated that based on the examination of the complainant she had formed an opinion that conservative surgical procedure like cone biopsy and follow up treatment would be sufficient in the case of the complainant. The 2nd opposite party has stated that the conservative management decision was given up as the patient was adamant to undergo hysterectomy and she had opted for LAVH. We are at a loss to understand how a doctor can change the procedure at the desire of a patient who is not conversant with the medical procedures. The 2nd opposite party, while giving evidence as DW2 has answered thus:-
)CW HM1LU \E7[Aka 8VCWAT<UBadWk8a \5T*a3LT\7T !\8T \CT,UBT\7T? (Q) !8a 8VCWAT<UdWk8a \5T*a3M 8[kBT7a} \CT,UBDc& =Li8W[*Tta AT`8^ [/BbUDc&(A) (Page 6 of deposition of DW2):- its translation Q) Who decides whether a surgery has to be performed or not? (A) It is the doctor who decides. It will not be done on the asking of the patient.
(e) The learned counsel for the 2nd opposite party has argued before us that a doctor is at liberty to choose a different line of treatment which is acceptable to medical standards. He has relied on a decision of the Hon'ble Supreme Court in Jacob Mathew Vs. State of Punjab (2005 (6) SCC - 1) and submitted that "a doctor cannot be held negligent simply because a patient has not responded favourably to a treatment given by a physician or that a surgery has failed". He has also a contention that the onus to prove negligence lies heavily on the complainant and in the instant case, the complainant has not proved her case to the satisfaction of this Commission. Citing 'Martin.F.D'Souza Vs. Mohd. Ishfaq(2009 (3) SCC - 1) the learned counsel submitted that doctors doing duty with reasonable care would not incur liability even if their treatment failed. He has further submitted that in the present case the complications that arose were common complications and the treating doctor, the 2nd opposite party had done everything to rectify the injuries that happened at the time of operation and hence the doctor cannot be held negligent or liable to pay compensation.
(f) Though we appreciate the contentions that a doctor is at liberty to choose a line of treatment acceptable to medical standards, we find that as per Ext.P10 the patient / complainant was referred to the physician for pre-operative check ups for TAH / BSO (Total Abdominal Hysterectomy / Bilateral Salpingo Oophorectomy) and the said doctor had recommended that the patient is fit to undergo TAH/BSO only. The doctor had written "Pt is fit to undergo the proposed surgery." It is clear that the said instruction for surgery was only for TAH / BSO and the same was done on 16/09/03 and the patient was subjected to surgery on 18/09/03. On showing Ext. P10 to DW-1, he has also stated that the fitness obtained was only for TAH / BSO and not for LAVH. It is also seen that at no point of time after 16/09/2003, the patient / complainant was referred for pre-operative check ups for LAVH. After physician's examination on 16/09/2003 at 11.30 A.M the patient left the hospital. If the 2nd opposite party, doctor, had her idea to conduct the LAVH she ought to have obtained the fitness for LAVH itself. Hence it is our irresistible conclusion that it was for TAH / BSO that the patient was prepared for and consent was also obtained for the said procedure. It is true that a doctor is at liberty to change the procedure in exigencies to save the life of the patient without written consent of the patient or her / his relatives. Here it is case of elective surgery. But if a different procedure is fixed other than the one for which the patient is prepared for, definitely pre-operative check ups for that procedure must be conducted and fitness obtained. So also there is no evidence to show that it was at the insistence of the complainant that the 2nd opposite party had proceeded with LAVH. If the complainant had such a desire as against the advise or decision of the doctor, the doctor could have rejected the patient or could have at least obtained a request in writing from the patient. In the absence of above circumstances we find that the contention of the 2nd opposite party that the LAVH was conducted at the instance of the complainant is only to be rejected.
(g) The learned counsel for the complainant has submitted before us that the 2nd opposite party had performed LAVH even though there were contraindications for the same. Relying on the literature "Recent Advances in surgery" edited by C.D.JohnsonMChir, FRCS, the learned counsel argued that disadvantages of laproscopic surgery are much more than TAH, as free blood from excessive bleeding absorbs light and degrades the laproscopic picture. The counsel has a case that when the 2nd opposite party has found that there was bleeding on touch and dense adhesions as are stated in the written version as well as in Exhibit B1 case sheet and Exhibit P3 discharge summary she ought not have selected LAVH in the case of the complainant. Inviting our attention to the literature "Ethical issues in laparascopic hysterectomy" by Shripad Hebbar and Sathisha Nayak, the counsel submitted that laparoscopic route is not ideal for severe pelvic adhesions, very large uterine fibroids and adnexal masses and the rate of major complaints for laparoscopic surgery are twice what it is for abdominal approaches. The counsel further referred us to the text "A Guide to Laparoscopic surgery by AZAD NAJMALDIN and PIERRE GUILLOU a Black Well science edition, which confirms contraindications and risk factors as follows:- Untrained / Inexperienced surgeon, Risk of bleeding, Blood obscures the view because it absorbs light, Poor view from excessive scarring and Dense adhesions. In the exhibit B1 case sheet it is specifically recorded about existence of scarring also. The findings in the operation notes of opposite parties in Exhibit B1 specifically states the presence of dense adhesions and in the Ext. P3 discharge summary it is recorded that bladder injury occurred due to dense adhesions between vagina and bladder. Further DW1, the medical superintendent, categorically admitted in the cross examination that "dense adhesion is a contraindication for doing LAVH and will not be done." The evidence and materials on record clearly establish that resorting to LAVH in this patient who is contraindicated constitutes deficiency in service and negligence.
(h) The 2nd opposite party, in her version, has admitted that the complainant's uterine cervix was found unhealthy and there was bleeding on touch and scarring. It is also stated that it was based on her examination that she had formed the opinion that conservative treatment like cone biopsy and follow up treatment would be advisable for the patient / complainant. Then it is to be found that if she had followed a different procedure she had done it at her own risk. The Hon'ble National Commission in "Smt.Saroj Chandhoke Vs. Sir Ganga Ram Hospital and another" (2007 (3) CPR 209 (N.C) has held that if a doctor carries out the surgery of his / her choice, he / she does so at his / her risk in case of mishap. The case also deals with violation of consent and its consequences. In the instant case it is to be seen that the 2nd opposite party had chosen the LAVH at her choice though she had initially decided to follow conservative treatment such as cone biopsy and follow up treatment. The said deviation on her own accord had led to the mishap and consequential damages on the complainant for which the 2nd opposite party alone is liable and responsible.
(i) Now regarding consent of the patient the learned counsel for the 2nd opposite party had argued that informed consent was obtained before the LAVH. On a perusal of the consent as contained in Ext. B1 we find that two consents from the complainant and her husband in one sheet of paper are obtained. It is also noted that it is a sheet of paper with printed matters which seem to be routine in every surgical procedure. It is further seen that one consent is a declaration consent and the other one is a consent given separately either by patient undergoing surgery or his / her relatives. However we observe that both consents are obtained on the one and same day (18/09/03) and nowhere in the consents, there is mention of LAVH. The learned counsel for the complainant has argued that the consent obtained was for TAH / BSO only. Further the fact that pre-operative checkups were done only for TAH / BSO as revealed by Exhibit P10 we can only agree with the contention of the counsel for the complainant that the consent was for TAH / BSO and not for LAVH. The Hon'ble Supreme Court in "Samira Kohli Vs. Dr.Prabha Manchanda (2008 (1) KLT SN 33 (C No.37) S.C) has held that a doctor should disclose (a) nature and procedure of the treatment and its purpose, benefits and effect (b) alternatives if any available (c) an outline of the substantial risks and (d) adverse consequences of refusing treatment. In the instant case it is noted that apart from obtaining signatures in a printed form there is no evidence to show that the 2nd opposite party had decided to conduct the LAVH on the complainant and the complainant had consented to the LAVH.
(j) The counsel for the complainant has vehemently argued before us that the 2nd opposite party had conducted the surgery without any tests like blood test before the surgery. The learned counsel for the opposite party has countered this argument by contending that it was based on the reports brought by the complainant that the surgery was done.
(k) However against this position DW3 has deposed:
2TN HM1LU <3fWk8U<a AWN=a "[NL \CT,U[B [?c5a[3HapW*PdW^ Apa [3HapW*PdW^ EU\;BATdTLWta& # [3Hapa *\t HM1LU <3fW*BWmX& A<WG_FCVCfUO )CWA7UdXM[*Tta ETD_WEU<a E_8_TH^ %tT*W^& Its translation - "Before I do surgery I subject my patient to blood test and other mandatory tests. Without examining the test results I will not subject my patients to surgery. The changes in blood values in a human body can occur in hours."
(l)DW3 is the 3rd opposite party and he is examined on the side of the opposite parties. The statement is that-
A<WG_FCVCfU[D C*a8fU[NL !JEU<a A7UdXLW*P [*Tta E_8_TH^ ECT^& Its translation - "Blood values in a human being can change within hours". The said statement has not been denied by any of the witnesses and the 2nd opposite party has also not deposed anything against the said statement.
(m) DW3 has also answered in the negative to a question put to him " blood [D Bio chemical values <W^ surgerydaAWN=a detect [/\Bbt *TC_hJUDW^ HM1LU patient "\kT [[,<Uda patient "\kT ![DcvUO cardiology patient "\kT E_8_TH^ medical science O %\tT ? $Dc& Its translation Q) Biochemical values in the blood has to be determined prior to surgery be it a case of urology, gynaecology or cardiology or is there any variations in the procedure among the three prior to surgery?
A) No (n) DW1, the medical superintendent who has represented the 1st opposite party who is a doctor himself has also stated that no blood test reports of the complainant are seen in the case records. (o) Though he would say that blood tests were done in the 1st opposite party hospital also there is no records for the same. However he has stated that he is ignorant about the question regarding reliance of test reports done at Bombay for treatment in the 1st opposite party hospital. The question and answer during cross examination are as follows:- Q) 27/03/03 <a \?T^[?BUO E/ba <3fUB [3HapW*[J #;TCATdUBT7a G.G.Hospital- DUO "DcT /U*U8aHBW^ <3fU[Bka =LBWk8a FCUBT\7T? !LUBUDb&
Its translation - Is it correct to say that the entire treatment given to the complainant in GG Hospital was based on the test report dated 27/03/2003 at Mumbai? (Q) I don't know (A)
(p) DW2 (OP2) herself has admitted that she had relied on the test reports produced by the complainant that were done sometime back in Mumbai. But DW3 has unambiguously stated that for conducting a surgery, the doctor should subject the patient for blood tests and other necessary tests immediately before the surgery as the blood values of human beings would change within hours. In the instant case the patient was suffering from heavy bleeding and it is recorded in medical records that the organs bleed on touch. Hence the requirement to ascertain bio chemical values in the blood was mandatory. The Hon'ble National Commission has also held that "the operating surgeon, before resorting to the operation should have carried out various laboratory tests like blood tests, urine tests etc.. to ascertain whether the patient was fit enough to undergo the surgery in question" (Dr. Kali Gounder Vs. Thangamuthu - III (2004) CPJ - 29 NC). In the present case even the treating doctor, the 2nd opposite party has no case that the complainant / patient was directed to undergo blood tests, urine tests etc... before the surgery and in the above circumstances it is our considered view that the 2nd opposite party had committed deficiency in service in the aspect of pre-operative tests like blood tests, urine tests etc... before she ventured into the LAVH on the complainant.
(q) The learned Counsel for the complainant has a further case that the 2nd opposite party was negligent and deficient in conducting the surgery (LAVH) and 2nd opposite party is liable for the consequences. It is argued by him that while doing the operation, the 2nd opposite party did not take proper care and caution and she had made a substantial cut forming 3" x 3" in the emptied bladder and also that both the ureters were included in the trigonal stitches and the ureters could not be released. Thus severe damages have occurred on vital organs which led to severe and permanent damage to the complainant.
(r) We have carefully analysed the said damage that has occurred to the urinary bladder as well as its consequences. This cut 3" x 3" is a massive injury to the bladder. The DW3 has stated that when he came to attend the patient the posterior wall of the bladder was already stitched. The DW3 added that he stitched the anterior wall and the lateral walls. Here an emptied bladder has been cut on all sides. The magnitude of the damage establishes that the 2nd opposite party was negligent. It has also to be noted that the LAVH surgery was done violating the consent which was taken only for TAH / BSO. The DW5 has stated that the damage of the sort that has happened is a rare complication. The urinary bladder has been severally damaged and the same has been unequivocally stated by DW3 and DW5. Further DW4 has stated clearly at page 5 of her deposition that uterus is a structure on the posterior side of the bladder and injuries can occur on the posterior side. The injuries in the posterior side alone constitute common complications. Apart from the substantial damage to the urinary bladder the both ureters were included in the trigonal stitches and the ureters could not be released. The Ext. XI (a) the operation notes of the DW5 at KIMS Hospital gives a lengthy narration of state of the bladder and ureters and the procedures done by him. It is pertinent to note that in Ext. B1 case sheet DW2 has suppressed the extent of injury and specific details of damage sustained to the organs. She had also suppressed the information from the bystanders. Hence on a careful analysis of the above fact we hold that the 2nd opposite party has committed negligence and deficiency in service. Further the patient had to undergo various curative operations and prolonged and continuous treatment as consequence of the negligence of the surgery. The decisions of the Hon'ble National Commission reported in 2007(3) CPR 209 (NC) Smt.Saroj Chandhoke Vs. Sir Ganga Ram Hospital and another and 2007 (2) CPR 24 (NC) S. Tamil Selvi Vs. Mrs. Dr. Sooriya Kala and another cited are squarely applicable to the facts of the case. The ratio of the said decisions applies to the case on all fours.
(s) It is also the complainant's case that the 2nd opposite party had sutured both ureters and the bladder together causing anuria. Thereafter it was at the KIMS Hospital that DW5 subjected the patient to a very complicated surgery and procedure which extended to almost 7 hours and the ureters were released applying stent enabling urine output of the patient. On a careful analysis, we find force in the said argument of the learned Counsel for the complainant.
The DW5 in cross examination has stated thus:-"Sutures remove ureters CtW^ dissect [/Ba8a stent $ea bladder O [*Tta -anastamosis (suture) [/Ba8W." - its translation -"sutures were removed and two ureters dissected and thereafter stent was applied and fixed to the bladder through anastamosis."He has also deposed that the ureters were entrapped due to sutures put earlier. It is to be found that DW3 had put stitches only in the anterior and lateral walls and not in the posterior wall. In the cross examination the DW2 did not specify the place where she stitched and she said "I have stitched the place where injury was found." That was evasive answer from 2nd opposite party. The 3rd opposite party maintained a specific stand in the version and proof affidavit that he did not stitch the posterior wall where the ureters are attached. He has also stated that he did not put any stitches in the ureters which are on the posterior side and since the above statements of DW3 are not controverted by 2nd opposite party, it can safely be concluded that the stitches in the ureters as well as in the posterior side of the bladder were put by 2nd opposite party herself.
(t) It is also to be found that when there was anuria for the complainant due to the stitches, the complainant was given lasix (medicine) twice for generating more urine than trying to find out the real reason for anuria. The 2nd opposite party while examined as DW2, has stated that she has understood that anuria was due to the block in ureters. Anuria is a stage where there is no generation of urine or where there is no urine output at all. The DW5 has also deposed thus:-
"Cta ureters <W^ 83HaH^ ECW\yTKT7a urine )eW^ ECT8UCUdWk8." He has further stated: "Bladder $] suture unit [< *X3U include [/Ba8UCWk8U<TDT7a urine ECT8UCWk8a .''- its translation - "Blockage of urine occurs only when there is obstruction to both ureters. It is the existence of suture that has caused blockage of urine." He has further stated: "the suture covering the bladder had included the ureters also and that has caused the blockage of urine." However Opposite party No.2 has posed ignorance about the sutures she had made after the LAVH. From the forgoing circumstances it is clear that anuria to the complainant was caused due to the stitches made by the 2nd opposite party. It is also to be seen when she understood that it was because of the block in ureters, she ought to have probed in finding out the reason for the block rather than giving lasix twice for generating more urine which is a serious lapse on the part of the 2nd opposite party. Further in the operation notes of DW3 in Exhibit B1 he has stated that "ureteral entrapment has to be evaluated" at 3 P.M and thereafter at 6 P.M DW3 has recorded that "will require exploration of both ureters entrapped." Though the 2nd opposite party has stated that lasix was given while the patient was in ICU either by the anaesthetist or by the duty doctor, she has admitted that it was given with her knowledge as well and hence she cannot shirk away the responsibility of giving lasix to the complainant when the complainant had been suffering from anuria as a consequence of entrapment. The Hon'ble National Commission in "Dr.Pushpamala Vs. K. Gangadharan& another 2011 (4) CPR 3 (NC) has held that drugs should be administered after proper examination of patient only and in instant case the 2nd opposite party can be held liable for the lapse of administration of Lasix without considering the warning of the urologist on entrapment and after being fully aware about the entrapment.
(u) The integrity of the 2nd opposite party has also been challenged by the Complainant. It is argued that the 2ndoppositeparty has deposed that she has not made any stitches at all in the ureters at the time of evidence only. It was belated shift in stand only at the time of cross examination. It is also seen that 2nd opposite party has stated that she was present at the time of surgery in KIMS whereas DW5 has deposed that 2nd opposite party was not present at the time of surgery in KIMS Hospital. On an evaluation of the deposition we find that the 2nd opposite party has tried to put the blame on DW3 the urologist, by deposing that she has not put any stitch in the ureters (page 14). Regarding the presence of 2nd opposite party at the time of surgery in KIMS Hospital 2nd opposite party has stated thus to a question as follows:-
Q) KIMS- O [E/ba $] \=G_NLU[< EVtW^ HM1LU <3fUB8a !LUBT\AT ? !LUBT^& A) # HAB^ 2TN operation 8VBpLUO %tTBUCWkW&- its translation
Q) Are you aware that the patient was subjected to surgery at KIMS? I know. At the time of surgery I was in the operation theatre.
(v) Against the above statement DW5 has stated as follows:- Q) KIMS - O surgery [/BbW\yTP 2- T^ "8_*RU Dr.Valsamma Chacko operation theatre - O %tTBUCW\kT ? $Dc& its translation A) She is also working in the KIMS Hospital. -- Whether the 2nd opposite party Dr.Valsamma Chacko was present in the operation theatre at the time of surgery? A) No: She is also working in the KIMS Hospital. (v) From the above statements we are only inclined to accept the contentions of the complainant and we are of the opinion that the 2nd opposite party ought to have been more truthful to her profession as a doctor. (w) The delay in transferring the patient / complainant to yet another hospital is another bone of contention between the parties. Though the learned counsel for the opposite parties had vehemently argued that there was no delay at all, the learned counsel for the complainant has submitted that when it was found that the patient had developed anuria and the 2nd opposite party was unable to handle the situation and as the urologist left the hospital on leave, she ought to have referred the patient immediately to another better hospital rather than inviting other doctors and wasting time. But relying on "C.P Sreekumar Dr. Vs. Ramanujam (2009 - (7) Supreme Court cases 130) the learned Counsel for the opposite parties has argued that "too much suspicion about negligence of attending doctors and frequent interference by Courts is a dangerous position and it would prevent doctors from taking decisions which could result in complications and in this situation patient is the ultimate sufferer." He has also submitted that Dr.Vikraman (DW5) was called for as the Urologist of the 1st opposite party hospital was absent on 19/09/03 and Dr.Vimala was also called for to solve the situation and it was at the advice of Dr.Vimala that the patient was shifted to KIMS Hospital for further treatment and that too at the option of the complainant's husband. (x) The learned counsel referred to written version and proof affidavit of 3rd opposite party the urologist who has stated the "patient's condition was critical" and also referred us to the nurses record in Exhibit B1 where the reason for reference to KIMS Hospital is stated as "As the urologist here was out of station patient is referred to KIMS for further management" and the progress notes at page 8 of Exhibit B1 it is stated by DW3 "will require exploration of both ureters entrapped" which was possible only through surgical intervention and that urine output chart revealed that from 3 PM to 6 AM total intake was 1200 ml and total output was only 90ml and he also referred to X1 case sheet where it is stated that 3 litres of urine was voided during surgery. The learned counsel clarified that the facts narrated above established that there was delay in referring the patient to a higher centre and the patient was left to the mercy of fate. We have carefully analysed the instances stated above and is found to be true and correct. (y) On an appreciation of the rival contentions of the parties, we find that even if the 2nd opposite party can be justified in summoning Dr.Sasikumar (DW3), the Urologist of their hospital to resolve the emergency situation but when DW3 had informed her that he would not be available thereafter it was imperative to transfer the patient to another hospital rather than waiting for other doctors from other hospitals to come. On a perusal of records we find that the operation was on 18/09/2003 and the patient was transferred to KIMS only at 11 A.M. on 19/09/2003 (Ext. P3) even when it was found that the urologist was out of station from 6 P.M on 18/09/2003 and the 1st and 2nd opposite parties could not manage the situation of the patient. It is further found that the 2nd opposite party had come to know about the condition of anuria and also the instruction given by DW3 to explore both ureters entrapped by 6 P.M on 18/09/03 itself and that a surgical intervention was required and hence we hold that there was delay in transferring the patient to a higher centre and the same constitutes deficiency in service. (z) Finally the learned counsel for the opposite parties had argued that the complainant was not successful in proving her case. He has submitted various citations to substantiate that in a case of deficiency in service on the part of medical professionals, the burden is heavy on the complainant to prove that there was deficiency in service. The learned counsel has invited our attention to the fact that apart from the depositions of PW1 and PW2 who are the complainant and her husband there is no expert evidence on the side of the complainant to prove deficiency in service on the part of opposite parties. Relying on the decision of the Hon'ble National Commission in Mini &others Vs. G. Mohan (Dr.) & Others (I) 2008 CPJ 201 (NC) the learned counsel argued that no relief can be granted to the complainant since the opposite parties have proved their case by examining experts and also produced supporting literature to establish the contentions of the opposite parties. (z 1) But relying on the decision of the Hon'ble Supreme Court in "V.KishanRao Vs. Nikhil Super Speciality Hospital " (2010(5) Supreme Court Cases 513) the learned counsel for complainant has argued before us that the Consumer Protection Act 1986 is intended to give speedy and simple redressal of consumer disputes and the said purpose cannot be defeated or diluted by super imposing requirements of having expert evidence in cases of civil medical negligence. He has further submitted that expert evidence is required only when the negligence cannot be proved by reliance on literature on medical field or otherwise and in the instant case the complainant has proved her case based on the evidence of opposite parties itself. It is also his case that the case on hand is a best example for invoking the principle of 'Res ipsaloquiter' as the complainant was a normal lady when she was subjected to the surgery by 2nd opposite party and now she is suffering serious adverse consequences and trauma after the surgery whereas if the surgery was proper and was done with due care and caution, she could have lived a perfect healthy life rather than undergoing frequent surgeries thereafter. (z 2) The learned counsel concluded by arguing that in the instant case pre-operative blood examination was not done in an elective surgery, that the consent was obtained for TAH / BSO and a different surgery was performed which was contraindicated and has led to substantial damage of vital organs and that the patient was under the "exclusive management" of the opposite parties and the PW1 was retained in the ICU of the 1st opposite party hospital in a critical state till 19/09/2003,11 P.M and hence is a fit case where the principle of 'res ipsaloqiutor' has to be applied and the evidence tendered by the opposite parties by itself prove negligence and deficiency in service. (z 3) On hearing both sides we find that on the side of complainant, only the complainant and her husband were examined. We also find that on the side of opposite parties, 5 witnesses were examined. But it is to be found that the witnesses except DW4 who are examined on the side of opposite parties are interested witnesses i.e, the medical superintendent of the 1st opposite party hospital (DW1), 2nd opposite party (DW2), 3rd opposite party (DW3) and Dr.Vikraman (DW5) who did the subsequent surgery and treatment and DW4 had been a student and worked as subordinate of 2nd opposite party. Any how the learned counsel for the complainant has argued the case relying on the depositions of witness of the opposite parties and judgments of Hon'ble Supreme Court and National Commission and also excerpts from medical text books. In this respect, we respectfully rely on the decision of the Hon'ble Supreme Court in Savitha Garg Vs. Director, National Heart Institute (2004 (8) Supreme Court Cases 56) where it is held that "once the complainant has discharged the initial burden that the hospital / doctor was negligent, then in that case the burden lies on the hospital / doctor to show that there was no negligence involved in the treatment." In the instant case we are satisfied that the complainant has proved her case and the 1st and 2nd opposite parties have failed in proving that there was no negligence at all on their side. Their spacious contention that the complications that happened at the time of surgery are common complications only can in no way be accepted. The extensive damage to the bladder and its severity along the subsequent conduct of the opposite parties leads the conclusion of negligence and deficiency in service in their actions. As observed by the Hon'ble Apex Court in "Spring Meadows Hospital Vs. Harjol Ahluwalia 1998 (4) SCC 30 very often in a case of compensation arising out of medical negligence, a plea is taken that it is a case of bonafide mistake / accepted complications which under certain circumstances may be excusable, but a mistake which would tantamount to negligence or deficiency in service cannot be pardoned." In this case the negligence and carelessness are proved beyond any shadow of doubt. In this case the principle of res-ipsa-loquitor also applies in its strict sense. In Prasanth S. Dhananka Vs. Nizam Institute of Medical Sciences (1999 (1) CPR 42 (NC). The National Commission has quoted the observation of the Supreme Court thus "gross medical mistakes will always result in a finding of negligence. The use of wrong thread or wrong during the course of anaesthetic will frequently lead to the imposition of liability and in some situations even the principle of res-ipsa-loquitor can applied. Even delegation of responsibility to another may amount to negligence in certain circumstances. A consultant could be negligent whether he delegates the responsibility to his junior with the knowledge that the junior was incapable of performing of his duties properly". In this case, the 2nd opposite party doctor cannot shirk the negligence which she directly committed to any other fellow doctor. Hence she is responsible and liable for the entire calamity and she cannot shift this burden to any other surgeon and physician. It is her sole burden. In the decision Swami Vs. Mathews (1968) (1) MALLJ 138 it is held that "every person who enters into the learned profession undertakes to bring to the exercise of its reasonable degree of care and skill". The doctor holding out ready to give treatment does undertakes that he is possessed of skill and knowledge for that purpose. The doctor must, therefore, bring to his task a reasonable degree of skill and knowledge and must also exercise reasonable degree of care. In the instant case the 2nd opposite party has failed to exercise reasonable degree of skill and care. The Supreme Court in Dr. Lakshman Balakrishna Joshi Vs. Dr. Trimbek Bapu Godbola & Another AIR 1969 SC 128 (1969) has laid down 3 guidelines to the members of the medical profession regarding the consultation and treatment of any patient. They are: (a) a duty of care in deciding whether to undertake the case; (b) a duty of care in deciding what treatment to give; And
(c) a duty of care in the administration of that treatment. A breach of any of these duties gives a cause of action for negligence to the patient. The negligence has many manifestations - as stated in Black's Law Dioctionary as collateral negligence, comparative negligence, concurrent negligence, continued negligence, criminal negligence, gross negligence, hazardous negligence, active and passive negligence, willful or reckless negligence etc. The 2nd opposite party doctor has committed carelessness and negligence during the course of the surgery of the complainant. Thus on going through the entire facts, evidence, arguments and circumstances of the case we find that the complainant is successful in substantiating her case of medical negligence against the 1st and 2nd opposite party who had committed negligence and deficiency in service as per the provisions of the Consumer Protection Act.
11. Issue No.3 Reliefs & Costs The complainant has sought for compensation of Rs.50 Lakhs for the negligence and deficiency in service of the 1st and 2nd opposite parties and another sum of Rs.20 Lakhs towards cost of medication and treatment with costs of Rs.30,000/- for the proceedings before this Commission. We have already found that there was deficiency in service and negligence on the part of the 1st and 2nd opposite parties. Though the complainant has impleaded the additional 3rd opposite party, no relief is sought against the 3rd opposite party and he has been made a party only for effective and proper adjudication of the dispute.
12. Now regarding negligence and deficiency in service it is found that the complainant was subjected to LAVH at the option of the 2nd opposite party only. No informed consent was obtained from the complainant or her husband. The surgery was conducted by the 2nd opposite party even when there were contraindications like bleeding on touch, dense adhesions, scarring etc. and the surgery was a total failure with complications like substantial damage to the bladder, entrapment of ureters which culminated in anuria to the patient. We have also found that the opposite parties 1 and 2 have committed delay in transferring the complainant / patient to a better hospital. The learned counsel for the complainant referred to the curative procedures undergone outside the Kerala State. The patient was subjected to curative surgeries at Mumbai. He referred us to Exhibit P7, the discharge card issued by M/s Jaslok Hospital at Mumbai which reveals continuous profuse vaginal leak and continuous urinary leak and Exhibit P8 Medical report of Dr. Phirose.F.Soonawalla, the Consultant Urologist &Andrologist attached to M/s Jaslok Hospital, Mumbai which extensively speak about profuse vaginal leak and urinary leak and the procedures undergone at M/s Jaslok Hospital and existence of urine leak despite procedures. Further Exhibit P9 the report of Dr.Rajamaheswari, Urogynaecologist of Chennai states that the patient presented with urinary leakage amounting to continuous urinary leakage -1 ½ years and reiterated that it establishes the pain, agony and trauma encountered by the complainant continuously along with substantial monitory expenditure. We find that there is force and merit in the said submissions.
13. The learned counsel for the complainant has submitted before us that the complainant was subjected to 4 more surgeries at different hospitals due to the negligence and deficiency in service of the 2nd opposite party in conducting the surgery. It is observed that in the 1stopposite party hospital itself the complainant had to undergo two major surgeries like LAVH and laparotomy. The complainant has submitted that she had been subjected to a major surgery in M/s Jaslok Hospital, Mumbai for VVF repair and various other procedures and another three surgeries were carried out at Dr.Rajamaheswari's Hospital in Chennai. We find that a huge amount had been spent by the complainant for the above surgeries apart from the trauma and other sufferings undergone by the complainant and her relatives. It is further observed that the complainant had been in the hospitals for about 140 days and even now the complainant is having complaints to control the urine which may fail at any time. The complainant has stated that she is under strong doses of antibiotics to protect her from urinary infections and has to continue the same for an infinite period. We find no reasons to disbelieve the complainant about the aspects stated supra. The exhibits P7 to P29 are the supporting evidence adduced by the complainant to prove that she sustained further physical strain and financial loss (after surgery). The patient who has experienced the consequences of negligence of careless operation from the 2nd opposite party doctor, has suffered continuous medical problems, physical weakness, mental agony and also huge financial loss. In the circumstances we are not in a position to blindly discard the claim of the complainant for the prayer of further compensation claimed by the complainant in the complaint. Hence she is also entitled to get compensation under these head. We considered these aspects also in this case. Hence we are of the strong opinion that the complainant has to be compensated by the 2nd opposite party who has been found to be negligent and deficient in her medical service. It is also found that the 1st opposite party is vicariously liable for the acts of the 2nd opposite party and hence the 1st opposite party is also liable to pay compensation.
14. In view of the above analysis we are of the opinion that the complainant is eligible for compensation. In this case the complainant had to undergo major surgeries at various hospitals apart from the 2 major surgeries undergone by her in the 1stopposite party hospital. She had to be in the hospital for 140 days at various spells and continues to be under strong medications. Though the complainant has prayed for a total sum of Rs.50 Lakhs as compensation our considered view is that the complainant is eligible for a total sum of Rs.22 Lakhs (Rupees Twenty two lakhs) as compensation for the negligence and deficiency in service on the part of the 2nd opposite party and cost of the treatment undergone by the complainant hitherto. The sufferings of the complainant/ patient are very terrible experience due to the carelessness and deficiency of service of the 2nd opposite party doctor. Due to her negligence the complainant was not in a position to pass the urine till the culmination of next day's surgery. The real reason for block is that the 2nd opposite party mistakenly and carelessly sutured the entire bladder with ureters of the complainant/patient and thereafter gave Lasix which aggravated her misery. In such circumstances she has been suffering intolerable pain and sufferings due to this wrongful act of the opposite parties. Further the urine leak could not be curbed. After all she is a human being. We direct that the 1st and 2nd opposite parties are jointly and severally liable to pay the amount to the complainant within a period of 2 months from the date of receipt of this order failing which the opposite parties 1 and 2 are liable to pay interest also @ 12% per annum from the date of complaint till the date of payment and the complainant is entitled to get a sum of Rs.20,000/- towards cost of the proceedings and is liable to be paid jointly and severally by the 1st and 2nd opposite parties. This complaint is disposed accordingly.
15. The learned senior counsel for the opposite parties submitted that Dr.Phirose F. Soonawala's, the author of exhibit P8 has not incorporated any register number of I.M.C etc in his prescription and hence his document cannot be accepted.
16. In the circumstances we direct the Travancore Cochin Medical Council, Kerala to give strict instructions to the all registered members in the council to exhibit their register numbers both in the sign board exhibited in their practicing area and in their prescriptions including the case sheet. It is necessary for getting a knowledge about the where-abouts of the competent and qualified medical practitioners for the consumers/patients. It is beneficial to the members of the profession and the patients accordingly.
17. The patient/consumer is having the right to know the details of each doctor who accompanied with the leader of the surgical team including the name of the anaesthetist. Any denial is a deficiency and unfair trade practice from their part according to the provisions of the Consumer Protection Act.
18. The registry of this Commission is directed to forward a copy of the judgment to the Chairman of the Council for necessary action for the interest of patients/consumers.
In the result the complaint is allowed in part as per the above findings and directions.
M.K. ABDULLA SONA: MEMBER A. RADHA : MEMBER APPENDIX COMPLAINANT'S WITNESS PW1 : Mrs. Leelamma Joseph PW2 : Sri. Joseph.J PW3 : Sri. Krishnan Nair.K.V COMPLAINANT'S EXHIBITS Ext.P1 : Original of opinion of Dr.S.D.Shinde of Ankur Maternity & Nursing Home, Mumbai.
Ext.P2 : Copy of post operative reference card issued by G.G.Hospital, Thiruvananthapuram.
Ext.P3 : Copy of discharge summary issued by Dr.Valsamma Chacko (2nd OP) of the G.G.Hospital, TVPM, dtd:19.9.2003.
Ext.P4 : Original of the discharge summary issued by Dr.Valsamma Chacko (2nd OP), Consultant Kerala Institute of Medical Sciences, dtd:7.10.2003.
Ext.P5 : Original of the treatment certificate issued by Dr.Valsamma Chacko, dtd:10.1.2004.
Ext.P6 : Original of the certificate issued by Dr.K.R.Vikraman, Senior Consultant, Urologist, dtd:10.1.2004.
Ext.P7 : Original of the discharge card issued by the Jaslok Hospital, Mumbai, dtd:3.3.2004.
Ext.P8 : Original of the Medical report issued by Dr.Phiroz F.. Soonawalla consulting Urologist & Andrologist of the Jaslok Hospital & Research Centre.
Ext.P9 : Original of the Medical report of Dr.N.Rajamaheswari, Urologist & Urogynaecologist, dtd:17.2.2005.
Ext.P10 : Original of the clearance certificate dtd:16.9.2003 issued by Dr.C.Krishnan Chettiar of the 1st OP hospital.
Ext.P11 Series :Copies of the medical bills issued by Hospitals, Medical shops, Laboratories, Scan centres etc. for the period from August 2003 to May 2004.
Ext.P12 series : Originals of medical bills issued by Hospitals, Medical shops, Laboratories, Scan centres etc. for the period from May 2004 till date.
Ext.P13 : Notarised copy of Cystoscopy report dated:24.2.2006 issued by Dr.N.Rajamaheswari.
Ext.P14 : Notarised copy of Surgical Pathology report dated:24.2.2006 issued by R & D Histopath Lab.
Ext.P15 : Notarised copy of Surgical Pathology report dated:12.3.2006 issued by R & D Histopath Lab.
Ext.P16 : Notarised copy of Patient Diagnosis report dated:1st April 2006 from Cancer Institute (WIA), Chennai-600020.
Ext.P.17 : Copy of letter dated:24.3.2006 issued by Dr.N.Rajamaheswari , Chennai-600020.
Ext.P18 : Notarised copy of Histopathology report dated:20.5.2006 issued by Dr.Anita Borges, S.L.Raheja Hospital, Mumbai.
Ext.P19 : Notarised copy of Histopathology report dated:25.5.2006 issued by Dr.Anita B Shah, Saifee Hospital, Mumbai.
Ext.P20 : Copy of letter addressed to Dr.V.Srinivas, Urologic Oncologist, PD Hinduja National Hospital, Mumbai, dated:24.7.2006 from Dr.Victor E Reuter, M.D., Vice Chairman, Department of Pathology, Memorial Sloan- Kettering Cancer Centre, New York. (Copy received from Dr.V.Srinivas for information) Ext.P21 : Notarised copy of examination notes of Dr.(Mrs) Sreelata V Gupta, Mumbai.
Ext.P22 : Notarised copy of Cytology report dated:19.8.2003 issued by Dr.V.K.Gupta, Mumbai.
Ext.P23 : Notarised copy of letter dated:26.8.2003 by Dr.(Mrs) Sreelata V Gupta, Mumabi.
Ext.P24 : Notarised copy of examination notes dated:26.8.2003 by Dr.S.D.Shinde, Mumbai.
Ext.P25 : Notarised copy of discharge card dated:28.8.2003 issued by Ankur Maternity & Nursing Home, Mumbai.
Ext.P26 : Notarised copy of Papinicolaou Smear report dated:28.8.2003 issued by SRL Ranbaxy, Mumbai.
Ext.P27 : Notarised copy of Histopathology report dated:1.9.2003 issued by SRL Ranbaxy, Mumbai.
Ext.P28 Series :
Ext.P28 (a) : Original blood grouping report dated:27.8.2003 issued by Suburban Diagnostics, Mumbai.
Ext.P28 (b) : Original complete blood count report dated:27.8.2003 issued by Suburban Diagnostics, Mumbai.
Ext.P28 (c) : Original printout dated:27.8.2003 of blood results.
Ext.P28 (d) : Orignal test results dated:27.8.2003 issued by
Suburban Diagnostics, Mumbai.
Ext.P28 (e) : Orignal urine examination report dated:27.8.2003 issued by Suburban Diagnostics, Mumbai.
Ext.P28 (f) : Original blood sugar report dated:27.8.2003 issued by Suburban Diagnostics, Mumbai.
OPPOSITE PARTIES WITNESS
DW1 : Dr. G. Haridas
DW2 : Dr. Valsamma Chaco
DW3 : Dr.N.P.Sasikumar
DW4 : Dr.Nazeema
DW5 : Vikraman.K.R.
OPPOSITE PARTIES EXHIBITS
Ext.B1 : Special power of attorney
Ext.B2 : Case record of G.G.Hospital
Ext.X1 : Case sheet of KIMS Hospital
M.K. ABDULLA SONA: MEMBER
A. RADHA : MEMBER
VL.
[ SRI.M.K.ABDULLA SONA] PRESIDING MEMBER