ORDER V.D. Gyani, J. --- 1. This letter petition by the prisoners Ranchod and Bhanta has been sent from Central Jail Indore. Cellulitis abcess caused by Chloroquine and Analgin injections to a patient hyper-sensitive to analgin and oxyphen-butazone, resulting in death in M.Y. Hospital, Indore on 18.11.1986, is the theme of this letter petition, sent by prisoners Ranchod and his father Bhanta, presently lodged at Central Jail, Indore, where they are undergoing life imprisonment. The petition has many facets exposing the negligence of authorities, callous disregard to duty by all concerned, including the Jail staff, the Executive Magistrate, the visitors to jail appointed by the State Government, the District Judge, the Police and the unethical conduct of the doctors. 2. Death takes no holiday. It knows no date and it is no respecter of persons. It occurs to the prince as well as to the prisoner. But when a prisoner dies, it does create some ripples. Vangariya, the prisoner who died, rather made to die, if the allegations made in this letter petition are true, on his refusal to wash clothes not only of the doctors and their family, but also of the nurses and compounders and do other all and sundry work at the jail doctor's bungalow landed him in the Jail hospital, where he was, as per allegations contained in the petition, and not denied by the doctor or the Compounder concerned, injected poison in the name of treatment, only because one cloths given for washing, was missing. 3. A Magistrial inquiry ordered into the death as it has to be under the rules, required to be held by a Sub-Divisional Magistrate, was delegated to a Tahsildar, who is still continuing with it, in face of a letter dated 27.11.1986 issued by the Collector, calling upon him to submit his report, if the inquiry was completed. This letter indicates that the inquiry was to be completed within a week or a fortnight, but even after a lapse of almost ten months, except for examining two or three witnesses and exchanging correspondence from one end to another there is hardly any progress made in it. If the order sheets, are any indication, this Magistrial inquiry is no better or worse than a mutation proceeding pending before a Tahsildar. The doctor and the compounder have proceeded on leave. If the order sheets, are any indication, this Magistrial inquiry is no better or worse than a mutation proceeding pending before a Tahsildar. The doctor and the compounder have proceeded on leave. They are not available for evidence and the Tahsildar has very comfortably posted the case for their evidence, after their return from leave Viscera preserved in this case, is still lying at the Police Station and the Station Officer is awaiting instruction from the Tahsildar as to what should be done in the matter. All this goes on unabated in face of the allegation that he was administered poison by the Jail doctor. The least that should have been done in the circumstances, and is legitimately expected of the authorities was to send the Viscera for Chemical examination at the earliest opportunity, but even after lapse of more than nine months, it has not been despatched to the Forensic Science Laboratory. 4. Vangariya, along with his father Bhanta and brother Ranchod and nephew was convicted by the Sessions Judge, Mandleshwar, for offence punishable under section 302/34 IPC and sentenced to undergo life imprisonment. He was admitted to Central Jail Indore, on 9.8.1986. His health as recorded at the time of admission was sound and good. He was assigned 'Safai' duty in the Jail Hospital from 1.9.1986 and continued as a 'Hospital Worker' in the Jail Hospital till he died on 18.11.1986. What a cruel irony of fate it was that his application for being released on bail came up for hearing just the next day, after the hearing of this petition, and his counsel who prayed and pressed for his release, little knowing that he had already been freed and released from the bonds of life itself, and no Court could have ordered his release. 5. The petitioners are his father and brother. They have alleged that some poisonous injection was given to Vangeriya who refused to wash clothes of the doctor, nurse and compounders. He was made to work at their residence after duty hours. He was much harassed for a missing cloths, subjected to mental torture and threatened by the compounder's to see him. These compounders and doctors have been specifically named by the petitioners, but none of them have come out with an affidavit to controvert the allegations made by Vangariya's father and brother. 6. He was much harassed for a missing cloths, subjected to mental torture and threatened by the compounder's to see him. These compounders and doctors have been specifically named by the petitioners, but none of them have come out with an affidavit to controvert the allegations made by Vangariya's father and brother. 6. The Jail Superintendent, while admitting that the deceased Vangariya was on Jail Hospital duty, has denied the allegations regarding washing of clothes and torture by officials. The return itself makes a shocking reading those who extracted work from the deceased, have not come forward to deny the allegations, but the Jail Superintendent wants us to believe that: "The convicts are not permitted to work at the residence of Compounder/Male Nurse and Doctors for Domestic work." May be that the Jail Manual prohibits such work being taken from convict prisoners, but can it not be violated? or is not violated? Permitting a convict to work at Jail Officials residence is one thing and actually extracting work is altogether a different thing. Rules may be there, but these are also violated with impunity. When the allegations are against the doctors compounders, nurse, by specifically naming them, they ought to have denied the allegations by filing separate affidavits. It is not the respondent's case that they are not available. They are very much available merely because some one has proceeded on leave, would also not afford a justification for not swearing an affidavit controverting the allegations. 7. Para 3 of the return reads as follows: "Contents of para 3 are false, hence it is denied. None of the official has tortured the deceased Vangeriya. It is not the duties of doctor or compounder to inject the injection of poison to other patients. It is admitted that the convict Vangeriya died on 18.11.86 in M.Y.H. Indore, but it is denied that the body of the deceased was totally swelled because of injection but in fact the deceased Vangeriya was admitted in Jail Hospital on 2.11.86 as he was suffering from fever. The doctor prescribed the medicines and the treatment was continued in Jail Hospital up to 14.11.86. On 12.11.86 the deceased Vangeriya complained for pain and abcess in left arm. The deceased was given treatment, for the same, but was not given a proper response by the petitioner, hence the deceased Vangeriya was shifted to M.Y. Hospital, Indore on 14.11.86. The doctor prescribed the medicines and the treatment was continued in Jail Hospital up to 14.11.86. On 12.11.86 the deceased Vangeriya complained for pain and abcess in left arm. The deceased was given treatment, for the same, but was not given a proper response by the petitioner, hence the deceased Vangeriya was shifted to M.Y. Hospital, Indore on 14.11.86. The general condition of the deceased Vangeriya was fit except the abcess in the left arm. The condition of the deceased was day by day deteriorated. The deceased was given proper treatment by well blood transmission. The deceased was operated at M.Y.H. Indore, but ultimately he died on 18.11.86" "The contents of the petitioner that the deceased died due to the injection of poison given by compounder is totally false and baseless. The report of M.Y.H. Indore is enclosed and marked Annexure R.I." To say that it is not the duty of the doctor or compounder to inject poison to other patients, is a mere wishful thinking, warmed and cooled by the same summer and winter doctors can also act in dereliction of duty. They can also be found to be remiss or negligent in .the discharge of their duty. 8. The contention that the deceased Vangariya was admitted to Jail Hospital on 2.11.86 where he remained till 14.11.86 stands amply contradicted by the Jail record itself. The attendance register of Hospital workers for the month of November 1986, shows Vangariya to be on duty. Letter 'P' indicating presence is put against his name, but this letter 'P' has been subsequently tampered with and converted into 'A', but the interpolation is so crude and prominent that is quite visible to a naked eye. 9. To be admitted to a hospital for treatment and to be in the hospital on 'Safai duty' are two distinct and different things. It is clear from the record that even while undergoing treatment work was extracted from the deceased. The crude interpolation with letter 'P' converting it into 'A' appears to have been done as an 'after thought'. 10. The matter does not rest here. Even the total number of hospital workers present has also been altered from 14 to 13, not for one or two days, but for full thirteen days up to 14.11.86. The crude interpolation with letter 'P' converting it into 'A' appears to have been done as an 'after thought'. 10. The matter does not rest here. Even the total number of hospital workers present has also been altered from 14 to 13, not for one or two days, but for full thirteen days up to 14.11.86. If the prisoner was hospitalised, as is claimed in the return, how can it be that he has been shown on duty as well for the same period. The affidavit sworn by the Jail Superintendent, particularly para 3 thereof reads as follows: "That the facts stated in para 1 to 6 of the return are true, based on the information derived from the official records of the State Government." To say the least, it gives a very distorted version and, therefore, lacks in inspiring confidence. 11. As per post mortem examination report, Vangariya died of shock due to septicemia and toxemia. Now, let us have a look at his medical treatment records. He was in Jail Hospital from 2.11.86 to 14.11.86. The total record consists of four sheets, with one ticket dated 2.11.86 for out-door patients, which shows that Vangariya was suffering from 'fever'. Provisional diagnosis on being admitted to M.Y.H. was injection abcess and cellulities which stands confirmed by final diagnosis that it was injection abcess and speading cellulitis. Patient's earliest record in the M.Y. Hospital ticket dated 14.11.86 for out door patient contains a caution that the patient was hypersensitive to analgin and oxyphen butazone, yet the patient was given analgin and chloroquine injections continously for five days. 12. In case of patients with known hypersensitivity when such contraindications are not heeded, the doctor is doing nothing but extending a cordial gilt-edged invitation to death. Ignorance of drug reactions is no defence. Before a doctor writes a prescription he must sort out in his mind known facts about patient's history and physical emotional status. Any disease identified with their etiology and preferred treatments available, his patient's medications, past present and future and environmental or hereditary factors, which might influence the prescribed medication, including congenital conditions, hypersensitivities, and indiosyncrasie. He must then avoid making any errors when writing the prescription. Rules for prescribing medication lay down that physicians must maintain accurate patient's record. Any disease identified with their etiology and preferred treatments available, his patient's medications, past present and future and environmental or hereditary factors, which might influence the prescribed medication, including congenital conditions, hypersensitivities, and indiosyncrasie. He must then avoid making any errors when writing the prescription. Rules for prescribing medication lay down that physicians must maintain accurate patient's record. He must be certain to list all medications taken past and present and carefully record any hypersensitivities, idiosyncrasies or other special situations that must be avoided in the future. 13. Medical record from Jail Hospital woefully lack in minimum requirements of prescription writing. Most physicians know how to write prescriptions and often neglect to write prescriptions in accordance with the rules for prescribing medication. The Jail doctor is no exception. In fact, the prescription has not been written by him. How devastating the effect can be, is demonstrated by importance of decimal point in the proper place, by shifting one place to the right causes, the patient to receive 10 times the dose intended. This error may prove fatal. A shift of one place to the left, causes the patient to receive 1/10 of the intended dose. This also can lead to serious consequences. 14. The patient Vangariya had injection abcess on the left arm. Injection of a drug into a muscle mayor may not quickly provide appropriate blood levels safely. It will, if the drug is in solution, in a suitable vehicle and is promptly absorbed with minimal trauma into blood vessels at the proper site of injection. It will not if the vehicle is irritating, or the injection technique is incorrect or the drug precipitates from solution because of the PH of the tissue fluids, or the drug is in a repository form. Apparently, all injunctions into muscles cause some trauma. Even intramascular IM lesions vary in intensity and character with the volume, speed, and depth of injection and with the type of medication. No physician can escape accountability to his patient if he persistently (1) applies inadequate diagnostic procedure (2) prescribes and administers unsuitable medications, or even appropriate ones improperly (3) uses a drug in categories of patients known to react adversely to that drug, (4) fails to act promptly to counteract serious adverse drug reactions, (5) provides incorrect drug information or directions for use, or (6) provides inadequate follow-up of patient response to medication. The patient may respondent unfavourably to medication when it is not properly selected, correctly prescribed, correctly dispensed, or appropriately administered. The medication selected for the patient should never be more hazardous than the disease to be treated. 15. Did my patient really sustain an adverse drug reaction? If so who is responsible? is a question which must be constantly asked by every conscientious physician to himself. Severe, sometimes irreparable damage to the body is too often caused by both over the counter and prescription medications. Because of serious reactions to one or more drugs in these medications. A drug reaction may be perceived through signs and symptoms or through abnormal clinical laboratory test results and it may manifest itself as a disease or syndrome. 16. Obviously, the term 'adverse' is only one of many qualifying adjectives for drug reactions. Dangerous effects may result from idiosyncrasy (susceptibility peculiar to a rare phenotype), hypersensitivity (hyper-reactivity often antigenic), over-dosage too large a dose given or taken internally for homicidal or suicidal purposes, or given or taken in error. What is expected of the physical in such cases? did the physician take all reasonable precautions? Did he inquire and test the patient to determine whether he was sensitive to the drug? Did he withdraw all other medication that might interact adversely with the one he wishes to prescribe? Did he allow time for elimination of long acting interfering medications? Did he warn the patient about taking over the counter medications concurrently? Did he check the diet for possible interactions? Did he carefully avoid all physical, chemical, and the rapeutic incompatibilities. The list of such questions is very long indeed. Did the physician personally observe the adverse reactions? Can he state, without reservations, that he personally observed the adverse drug reaction take place after he administered the implicated drug so that a definite cause and effect relationship was clearly established? Physicians have injected penicillin into patients who immediately suffered anaphylactic shock and died. In a case with such an instantaneous-response, there can be little doubt that the drug caused the reaction. On the other hand, physicians have occasionally reversed their conclusion that a given drug had caused a certain reaction, when more information became available. Did the drug reaction pose an immediate or potentially serious hazard? In a case with such an instantaneous-response, there can be little doubt that the drug caused the reaction. On the other hand, physicians have occasionally reversed their conclusion that a given drug had caused a certain reaction, when more information became available. Did the drug reaction pose an immediate or potentially serious hazard? To summarise, the following are the proofs of negligence on the part of the physician: i) treatment of a condition with a drug not suitable for the condition; ii) failure to note a history of allergy to the drug administered; iii) use of improper injection technique; iv) failure to stop treatment with a drug as soon as a reaction occurs, and, v) failure to provide adequate therapy to counteract a reaction when it occurs. 17. The record does not show any such precaution being taken by the Jail doctor. On the other hand he admitted before this Court, when he was present during the course of hearing of this petition, that prescription was written by the compounder, who also administered the injection. It is an act of callous disregard to duty. 18. Now, recall to mind at this stage, the averment made in the return: "It is not the duty of the doctor to inject poison". Drug injection may itself prove to be poisonous. This is what the poor illiterate tribals really mean, when they complain of administering poison. 19. On 14.11.1986 the prisoner was transferred to M.Y.H. Indore in a very serious condition, as can be gathered from the treatment-card. At 11.40 p.m. on 14.11.1986 the Telephone Operator was instructed by the doctor incharge to inform the concerned police station to arrange for recording a dying declaration. This itself goes to show the precarious condition in which the patient was. Accordingly a telephonic message was given by the Telephone Operator, Sharad Kulkarni, to both the Police Station, Mahatma Gandhi Road, Indore, as well as the Police Control Room. He has also sworn an affidavit in support of the endorsements made by him on the treatment-card, to the effect that telephonic message for recording a dying declaration given and also recorded the names of the police officers receiving the message on the other end. He has also sworn an affidavit in support of the endorsements made by him on the treatment-card, to the effect that telephonic message for recording a dying declaration given and also recorded the names of the police officers receiving the message on the other end. Inspite of this message no arrangement appears to have been made for recording dying declaration till 4.00 a.m. As endorsement made at 4.00 a.m. on 15.11.86 on the treatment card, reads: "Patient is not fit for giving a dying declaration". There is also yet another endorsement to the effect that a "Radio message from the District Magistrate through constable Ashoksingh of police station Bhanwarkuwa was received at the M.Y. Hospital at 3.45 p.m. asking for the sister on duty to call the doctor. A copy of the entry made in the General Diary of Police Station Bhanwarkuwa at Serial No. 1228 on 15.11.86 at 1.50 a.m. has been placed on record by the respondents. According to this entry one Naib Tahsildar, Shri Pagare, was informed by constable Ashoksingh to proceed to M. Y. Hospital for recording dying declaration of the patient. What is surprising is that right from 11.60 p.m. to 4.00 a.m. inspite of intimation received, no Magistrate proceeded to the Hospital for recording a dying declaration, thereby lotting out a valuable piece of evidence, which would have come from the mouth of the deceased. Silence so thrusted upon him has made it more compelling than any retoric, to ask the question as to why the doctor on duty could not record, as they sometimes do, what made him, not to record a dying declaration? 20. The record does not indicate that the Naib Tahsildar, who was informed by the police constable Ashoksingh even bothered to proceed to the Hospital. On the other hand, what the endorsement on the treatment-card dated 14.11.86 goes to show is that the constable visited the Hospital at 3.45 a.m. It appears that the Naib Tahsildar, who was approached by the constable around 1.50 a.m. instead of rushing to the Hospital, directed the constable to ascertain whether the patient was still in a condition to make a dying declaration. This lethargy on the part of those who are entrusted with the task of recording dying declarations, deserves to be deprecated. A dying man cannot be expected to wait for arrival of the Magistrate. This lethargy on the part of those who are entrusted with the task of recording dying declarations, deserves to be deprecated. A dying man cannot be expected to wait for arrival of the Magistrate. It is the Magistrate, who should rise to the occasion and rush up to the dying man without any loss of time. Any remissness on his part results in shielding of truth as in the instant case. No one knows that statement the prisoner would have made, had he been immediately contacted on receiving information. 21. An endorsement about the patient not being in a fit condition for making a dying declaration has been made on the treatment card. The question is as to who made it? How the condition deteriorated within four hours or is that the endorsement itself was an attempt at screening the truth which otherwise would have come from the mouth of the deceased. Vangariya, even while undergoing the agony survived and accommodate himself to the inevitable, before the worst was over, for another three days. But none, neither the police, who was informed, nor the Magistrate, nor did the doctors bother to record any statement. The record is silent about the silence so mysteriously thrusted on Vangariya. 22. There is yet another disturbing feature of the treatment record of the M. Y. Hospital, Indore. At one stage it was felt necessary to operate the patient and the consent for such operation was given by the constable, who escorted him. It is extremely shocking as to how a constable, escorting a prisoner could consent to any operation, particularly when the patient himself was unconscious. How such a consent could satisfy the conscience of the doctor. It is nothing short of dehumanising the patient, although just underneath the constable's signatures on the consent endorsed by him, there is also the signatures of the Superintendent of the Central Jail, Indore, but it does not stand to reason that if the Superintendent of Central Jail was available for such a consent, what was the occasion for obtaining it from the constable escorting the prisoner? The irresistible inference in such circumstances is that the Superintendent of Central Jail subsequently put his signatures. It is clear from the fact that it does not bear any date. The record shows that I and D done under GA on 14.11.86. The irresistible inference in such circumstances is that the Superintendent of Central Jail subsequently put his signatures. It is clear from the fact that it does not bear any date. The record shows that I and D done under GA on 14.11.86. The patient who was already unconscious and known to be so to the doctors, was operated under general anaesthesia, there can be an honest difference of opinion amongst the doctors on this point, the doctor may operate on his own but to obtain consent from the police constable is something, which does not appeal to reason. It is as though the prisoner was not a human being, but chattel or property belonging to the constable. It is not only consent but informed consent of the patient or his relation or guardian, which could possibly afford any protection to the doctor in the event the operation is called in question. Unfortunate as it is, Vangariya, the patient was also a prisoner and virtually reduced to a sub-human level by the doctor, when the constable's consent was obtained for operation. How could he take upon himself the authority of consenting to an operation, that too in a condition when the patient himself was unconscious. All this had happened in face of the irrefutable fact that the patient's brother and father were very much available in the same prison, wherefrom the prisoner Vangariya was brought to the hospital. But neither the doctor nor the Superintendent of Central Jail bothered, at least the record does not show, to obtain consent from anyone of them. Yet, it may be claimed, that the operation was successful, but the patient is dead. 23. There is yet another human aspect of this letter petition, which deserves attention. The father and brother were all along kept in dark as though they had nothing to do with the flesh of their own flesh and blood of their own blood Vangariya. When blood transfusion became necessary, patient's father and brother were not taken out of their cells to donate blood. It is also not borne out from the record that their blood-group was tested and found as not suitable, nor does the record show that even in that precarious condition they were allowed a visit to the patient. When blood transfusion became necessary, patient's father and brother were not taken out of their cells to donate blood. It is also not borne out from the record that their blood-group was tested and found as not suitable, nor does the record show that even in that precarious condition they were allowed a visit to the patient. From 14th to 18th November, 1986, when Vangariya was in M.Y. Hospital, the jail record does not show that either the father was taken to the hospital to see his dying son, who was gasping for every breathe of his life nor his brother taken to meet his dying brother. Even decency of death was denied. Possibly the authorities were competing in the glory of Jail discipline, sacrificing human values. 24. This letter petition brings into sharp focus and throws light on many other ills besetting the system. Do our District and Sessions Judges, who are ex-officio visitors to the Jail within their respective jurisdiction, the Director of Health Services, the Civil Surgeon or Medical Officers, the representatives of people representing particular urban or rural constituency in the State Legislature and the non-official visitors, as appointed under Regulation No. 815 of the Jail Manual, do they satisfy themselves that the law, rules regulating the management of prisons and prisoners are duly carried out. Their duties are enumerated in Regulation No. 817 of the Jail Manual. They can call for and inspect any book or other record in the Jail. Have they regularly visited the Jail so as to apprise themselves of the genuine problems the prisoners are facing and their grievances, the nonofficial visitors to the Jail, appointed by the State Govt. have they justified their appointment by getting themselves acquainted with the prisoners problems and making efforts for amelioration of their lot, within the framework of the Jail Manual itself. If all this had been going on smoothly, as is expected and sought to be possibly there was no need for Ranchod and Bhanta to make this letter petition. The question looms large, who bothers, much less mourns for the prisoners. What the prisoner-petitioners prayed is a direction for holding an inquiry, which is, as stated above, is already going on. We can only direct it to be expedited. The question looms large, who bothers, much less mourns for the prisoners. What the prisoner-petitioners prayed is a direction for holding an inquiry, which is, as stated above, is already going on. We can only direct it to be expedited. Through probe in the whole episode and even criminal prosecutions of those found to be responsible, in the circumstances, suspicious as they are, is a must. 25. If the Magistrial inquiry, which is going on is not to be reduced to a farce by mere exchange of correspondence from one and to other and has to serve any meaningful purpose, it ought to have been completed long back. But unfortunate as it is in face of allegations of poisoning, the viscera has not yet been sent for chemical examination. The suspicious circumstances in which Vangariya died, calls for a thorough probe. We, therefore, direct the respondent No.1 to hold a thorough probe into the matter and proceed in accordance with law against those found to be remiss or negligent in their duty. Criminal prosecutions be launched against those found to be guilty. The probe, as directed above, is independent of the Magistrial Inquiry, which is going on. The probe, as directed above, must be completed within the period of forty-five days from the date of this order and those found guilty must be proceeded against in accordance with law. A copy of this order be sent to the State Government.