ORDER Mr. Justice K.S. Gupta, Presiding Member: Complainant No.1 widow and complainant Nos. 2 and 3, minor children of Naveen Kant, jointly filed this complaint inter alia alleging that for the first time in April, 1990 Naveen Kant developed hypertension and was under the treatment of Dr. P.O. Gulati, Nephrologist. On 15.5.1995, Dr. Gulati advised him for renal transplantation. Since 1.6.1995, Naveen Kant underwent regular maintenance dialysis at Tirath Ram Shah Hospital, Delhi under the supervision of Dr. Gulati. In Junel July 1995. from their friends and acquaintances Naveen Kant and complainant No. 1 learnt of Dr. Muthusethupathi-opposite party No.1, a Nephrologist of repute at Madras. On 31.7.1995, Naveen Kant: complainant No.1; A.V. Krishna, brother of complainant No.1 and O.J. Somasundaram met opposite party No. 1. He was shown the entire medical record. After examining Naveen Kant, the opposite party No. 1 agreed to perform renal transplantation for him. On 25.8.1995, opposite party No.1 examined the suitable donor to assess his kidney's compatibility with Naveen Kant's system. On 8.9.1995, Naveen Kant and the donor jointly wrote the Authorising Committee constituted by the Government of Tamil Nadu vide G.O. Ms. No. 287/ Health dated 15.5.1995 for approval. In their meeting held on 15.9.1995 the Authorisation Committee approved the proposed transplantation. On 17.9.1995, opposite party No. 1 advised Naveen Kant to continue to have dialysis twice a week and wait his turn for transplant operation. After waiting for four weeks and finding that there was no immediate prospect of his turn reaching, Naveen Kant returned to Delhi. He continued to have dialysis twice a week as advised by opposite party No. 1 at Tirath Ram Shah Hospital. On 31.10.1995, Naveen Kant and complainant No. 1 returned to Madras and consulted the opposite party No. 1 who indicated that the operation might be done on 12.11.1995 at opposite party No.6 Aswini Soundra Nursing Home On 10.11.1995 amount of Rs. 1,10,000 to wards medical fee and expenses was paid partly in cash and partly through :'In account payee cheque to opposite party No. 6-nursing home. On 12.11.1995, kidney transplant was performed by a team of about twelve doctors headed by Dr. P.S. Venkateswaran-opposite party No.5; a Consultant attached to opposite party No. 6. Opposite party No. 1 joined the team in operation. After operation, opposite party Nos. 1 and 5 informed the complainant No. 1 of the transplantation being successful. On 12.11.1995, kidney transplant was performed by a team of about twelve doctors headed by Dr. P.S. Venkateswaran-opposite party No.5; a Consultant attached to opposite party No. 6. Opposite party No. 1 joined the team in operation. After operation, opposite party Nos. 1 and 5 informed the complainant No. 1 of the transplantation being successful. From the operation theatre both the donor and Naveen Kant were shifted to ICU for post-operative care. Complainant No. 1 was not allowed to go near them. On 15.11.1995, complainant No. 1 was informed by the nursing staff on duty that her husband had developed infection and malaria for which certain medicines were given. Complainant No. 1 and other family members were allowed to see Naveen Kant only with facemask and that too for few minutes in a day in the ICU. On 20.11.1995, donor was discharged from opposite party No. 6-nursing home. On 24.11.1995, Naveen Kant too was discharged with direction to attend as an out patient for dressing of the wound at the place of incision. It was alleged that while still in ICU, Naveen Kant had complained of pain in his left forearm where intravenous drugs were injected to opposite party Nos. 1 and 5 who assured that the pain would disappear in due course. On the same day, in the evening, Naveen Kant and complainant No. 1 attended the clinic of opposite party No.1 for review when NaveenKant reiterated his grievance of pain in the left forearm. From 24.11.1995 onwards, Naveen Kant accompanied by complainant No. 1 and/ or one of his family members attended the clinic of opposite party No.1 or opposite party No.6-nursing home almost daily. On 30.11.1995, opposite party No. 1 noticed the onset of cellulitis in Naveen Kant's left forearm and he referred him to opposite party No.5. After his first abscess burst on 2.12.1995, there was recurrence of the same abscess at other point(s). Still the doctors did not take it seriously and conducted investigations into the cause of pain. On 16.12.1995, Naveen Kant developed severe headache coupled with loss of proper vision in the right eye. On 20.12.1995 he further had a bout of vomiting. Complainant No.1 pointed out these problems to Dr. K. Yathindra Kumar, dialysis in charge of opposite party No.4-hospital, who used to administer necessary I.V. injections and. do the dressings. On 16.12.1995, Naveen Kant developed severe headache coupled with loss of proper vision in the right eye. On 20.12.1995 he further had a bout of vomiting. Complainant No.1 pointed out these problems to Dr. K. Yathindra Kumar, dialysis in charge of opposite party No.4-hospital, who used to administer necessary I.V. injections and. do the dressings. On 21.12.1995, on the advice of opposite party No.1, Naveen Kant was admitted to opposite party No. 4-hospital. At about 4.00 p.m. Naveen Kant became unconscious. He was seen by opposite party No.1, Dr. Kumaresan, a Neurologist and opposite party No. 3Dr. K.K. Bhat. He was administered anti convulsion injection. On 22.12.1995, Naveen Kant was attended by opposite party Nos. 1, 3 and 5 and Dr. Kumaresan. Headache, fever and pus in his left forearm still persisted. Opposite party No.5 made a long incision in the left forearm to drain-off the pus. It was stated that thereafter till 30.12.1995, opposite party No. 1 became unavailable. He had instructed Dr. S. Shivakumar-opposite party No.2 to attend to Naveen Kant without giving him clear instructions. On 23.12.1995, Naveen Kant developed drowsiness and lost control over the bladder and bowels and a CT Scan of brain was done but it revealed no abnormality. Pus culture showed no growth. On the night of 25.12.1995, Dr. Minni Dutta, MD Paediatrics and DNB, sister of complainant No.1, came to Madras. From 26.12.199.5 onwards she consistently remained in touch with the opposite parties. On 26.12.199.5 a bedscan Ultrasound was done which disclosed that Naveen Kant had small abscess in pancreas and liver. On 27.12.1995, X-ray was taken which showed some abnormal developments in the lung. On 29.12.1995 in addition to Fortum I.V. and Amikacin I.V. already being given for the existing infection, the doctors prescribed anti-tubercular treatment (ATT) as well as injection Vancomycin for septicaemia. On 3.1.1996, Naveen Kant's sodium level dipped sharply and he became comatose. ATT was suspended. On 4.1.1996, a bedscan ultrasound revealed that the infection had spread to the pancreas. Opposite party Nos. 1 and 3 resorted to administering different antibiotics to contain the spread of infection. On 7.1.1996, opposite party No.1 was stated to have admitted to Mrs. Vimla Akhouri, sister-in-law of complainant No.1, that Naveen Kant was in advanced stage of septicaemia. On 4.1.1996, a bedscan ultrasound revealed that the infection had spread to the pancreas. Opposite party Nos. 1 and 3 resorted to administering different antibiotics to contain the spread of infection. On 7.1.1996, opposite party No.1 was stated to have admitted to Mrs. Vimla Akhouri, sister-in-law of complainant No.1, that Naveen Kant was in advanced stage of septicaemia. Despite this, the doctors maintained a routine treatment and made no concerted efforts to contain the septicaemia either in terms of required potency of antibiotics administered or the quality of these antibiotics or otherwise. After a gap of 9 days on 12.1.1996 ATT was resumed. As Naveen Kantwas having low grade fever ATT was given for 12 days. On 24.1.1996, a CT scan of brain to rule out meningitis was done which showed that there was no meningial feature present. On 27.1.1996, lumbar puncture was done. On 28.1.1996, Naveen Kant went into delirium during the night. On 30.1.1996 he developed breathing problem. He was moved to ICU on instnictions of Dr. K.K. Bhat-opposite party No.3. In the morni'ng of31.1.1996, opposite party No.1 visited Naveen Kant who was in unconscious state. He advised shifting from opposite party No.4 to opposite party No. 7-St. Isabel's Hospital. At opposite party No.7-hospital, the opposite party No. 1 visited him. He called Dr. Kumaresan and Dr. Venkatesan. Naveen Kant was fed through Ryle's tube and suction catheter was used to clear his throat. Certain blood tests were conducted. His condition continued to deteriorate and ultimately he died on 3.2.1996. Attributing negligence on the part of said treating doctors and the hospitals, following amounts have been claimed by the complainants : A. Special Damages Amount (in Rs.) (i) Pain and suffering and loss of amenity undergone by late Shri Naveen Kant 20,00,000.00 (ii) Actual medical fees and expenses incurred from June. 1995 to Feb. 1996. 3,40,382.00 (iii) Travelling, boarding and lodging expenses incurred in connection with Naveen Kant's hospitalization and treatment at Madras. 3.10,038.00 B. General Damages (i) Loss of dependency for the projected life of late Sri Naveen Kant. Rs. 87, 753x18 (multiplier) 15,77,754.00 (ii) Expenses on education and tuition of complainants 2 and 3 at Rs. 2,000 per month for the next 12 years. 2,88,000.00 (iii) Pain and mental agony and permanent deprivation of consortium and paternal nurturing suffered by complainants. 50,00,000.00 Total` 95,16,174.33 2. Opposite party No.1 contested the complaint by filing reply on affidavit. Rs. 87, 753x18 (multiplier) 15,77,754.00 (ii) Expenses on education and tuition of complainants 2 and 3 at Rs. 2,000 per month for the next 12 years. 2,88,000.00 (iii) Pain and mental agony and permanent deprivation of consortium and paternal nurturing suffered by complainants. 50,00,000.00 Total` 95,16,174.33 2. Opposite party No.1 contested the complaint by filing reply on affidavit. It was alleged that the members of the team who performed the renal transplant operation, are the experts in their field and had conducted more than 900 renal transplants with very good results. This is one of the rare cases where the patient died despite the best efforts of the doctors. Answering opposite party No.1 is M.D. (General Medicine) from Stanley Medical College. After working as an Assistant Professor of Medicine in various medical colleges in Tamil Nadu, he joined the Post Graduate Institute (PGI) for D.M. Nephrology Course in i 975. He got his D.M. degree in 19/7. He trained more than 48 candidates for the degree of DM Nephrology and DNB Nephrology and has won many awards. Opposite party No.2 did his MD in General Medicine in 1977 and he joined the Tamil Nadu Government Medical Service. He became Assistant Professor of Medicine in 1978 and remained Assistant Professor of Nephrology in the Department of Nephrology during 1987 to 1997. Now he is the Professor of Medicine in Stanley Government Hospital, Chennai and has published many papers in Nephrology. Opposite party No.5 passed M.S. (General Surgery) in 1978 and obtained MIC Vascular surgery qualification. He worked as Assistant Surgeon in Tamil Nadu Government service from 1977 to 1983. He worked as an Assistant Professor of Surgery from 1983 in Royapettah Government Hospital, Chennai. He was promoted as Professor of Surgery in Tamil Nadu Government Service in the year 1977. At present he is working as Honorary Professor of Surgery and as a Senior Civil Surgeon at Government General Hospital and Madras Medical College, Chennai. He has .extensive general surgical and vascular surgical experience of nearly 30 years and he is one of the senior most surgeons in Tamil Nadu Government Service. Since 1985 he has performed over 500 kidney transplant surgeries. He trained 60 candidates for MS (General Surgery) and presented several academic papers and attended several conferences. Kidney transplantation team at 6th opposite party-nursing home has been functioning since 1985 and has performed over 500 kidney transplantations till date. Since 1985 he has performed over 500 kidney transplant surgeries. He trained 60 candidates for MS (General Surgery) and presented several academic papers and attended several conferences. Kidney transplantation team at 6th opposite party-nursing home has been functioning since 1985 and has performed over 500 kidney transplantations till date. The facilities at the post transplant intensive care unit of opposite party No. 6nursing home are of a high standard and there is no possibility of acquiring infection from ICU. Patients are kept under barrier nursing to ensure that they do not acquire any infection from the hospital environment. It was stated that Naveen Kant was in opposite party No.6-nursing home till 24.11.1995. Record of the nursing home for the period from 10.11..1995 to 24.11.1995 would show that surgery was successfully performed on 12.11.1995. On 13.11.1995, patient developed low-grade fever for a few hours in the morning. There was no other evidence of bacterial infection. Naveen Kant was given injection Reflin. The temperature normalized, in the afternoon. On 14.11.1995, Naveen Kant had fever and chills. Blood culture was sent for lab test and injection Fortum was started. Blood test for malaria parasite was positive. Nivaquine was started. Blood culture for bacteria was negative. Naveen Kant attained normal temperature from 15.11.1995 and remained so till discharge. On 17.11.1995, Urine Catheter tip grew Klebsiella though urine culture was sterile. A course of cyprofloxin was started on 20.11.1995 and was continued for •five days. Had there been any complaint by Naveen Kant of pain in forearm or of any other infection it would have been looked into very carefully. There was no evidence of any infection. Naveen Kant was doing well at the time of discharge. It was stated that rise in total leucocyte count is common in immediate post transplant period and does not necessarily imply any infection. Immuno suppressive drugs which were given to Naveen Kant. were essential to prevent rejection of the transplanted organ. When immuno system is suppressed, bacteria from individuals' own body can cause infection. After discharge, as per practice, a patient is called in opposite party-clinic three times a week to begin with and than at frequent intervals depending on the condition of patient. were essential to prevent rejection of the transplanted organ. When immuno system is suppressed, bacteria from individuals' own body can cause infection. After discharge, as per practice, a patient is called in opposite party-clinic three times a week to begin with and than at frequent intervals depending on the condition of patient. From pages 169 to 173 of the Annexures, it is clear that Naveen Kant's progress was quite satisfactory until 30.11.1995 when it was noticed that he had developed fever on that day and had cellulite is in left forearm. Reflin which is one of the best antibiotics for cellulites was started. On 4.12.1995 it was found that temperature was settling but on 5.12.1995 Naveen Kant was febrile. Therefore, injection Amikacin was added. On 6.12.1995, abscess was incised and drained by opposite party No.5. When Naveen Kant visited the opposite party No.1 on 12.12.1995 he was having temperature. Medicine Quintor was added. The fact that abscess was incised and drained on 6.12.1995 has not been disclosed deliberately in the narrative chart at page 63 annexed with the complaint. On 18.12.1995 temperature was found to persist and there was indurations in the left forearm. Test for malaria was positive. Nivaquine was, therefore, given. On 16.12.1995, totalleucocyte count was high with 91 % polymorphs. Naveen Kant was started with Vancomycin for 'probable infection. He was advised to get admitted in the hospital. Naveen Kant himself chose opposite party No.4-hospital. He was admitted in that hospital on 21.12.1995. On that day answering opposite party and Dr. Kumaresan visited him when blood, urine and pus culture were sent for test and he was started on injection Fortum and Amikacin. On the same day at about 4.00 p.m. Naveen Kant was found unconscious. Dr. Kumaresan saw him and prescribed Epsolin. He regained consciousness when Dr. Kumaresan was admiring to him. Fever continued. Opposite Party No. 1 was out of town from 23.12.1995 to 30.12.1995. Patient was looked after by opposite party No.2-Dr. S. Shivakumar, Assistant Professor of Nephrology who has been the colleague of opposite party No. 1 and assisted him over 10 years and was fully conversant with the problems of kidney transplantation. Naveen Kant was looked after by Dr. Kumaresan, opposite party No. 2 and Dr. Bhatt. The cultures were reported negative. On 23.12.1995, opposite party No.5 made an incision and evacuated the pus from the left forearm. Naveen Kant was looked after by Dr. Kumaresan, opposite party No. 2 and Dr. Bhatt. The cultures were reported negative. On 23.12.1995, opposite party No.5 made an incision and evacuated the pus from the left forearm. He was given a course of Mefloguin for possible malaria. On 26.12.95 opposite party No. 5 noted that the wound was healthy and there was no purulent discharge of pus. Naveen Kant was conscious though the complainants mention about the alleged headache and drowsiness. Despite higher antibiotic therapy Naveen Kant continued to have fever. Dr. Natarajan, Professor of Chest Diseases and Tuberculosis at Government General Hospital was called in. He saw Naveen Kant on 28.12.1995 and considered the possibility of Tuberculosis. He suggested that injection vancomycin be started and if there was no response it be substituted with anti-tuberculosis treatment. His advice was followed. On 31.12.1995 Naveen Kant continued to have fever and Cifron, Metrogyl, Vankomycin and anti-TB drugs were administered. On 2.1.1996, indurated area at the site of incision was noted in the left. forearm. Injection Aztreonam was started. On 2.1.1996 it was opened and pus was let out. Repeated blood and urine cultures were negative. On 4.1.1996, temperature was settling and patient was conscious with clear lungs. Ultrasound abdomen showed four hypoechoic areas in the pancreas. Same treatment was continued. Naveen Kant was having fever continuously and was under constant observation and treatment. On 16.1.1996, CT abdomen showed hypodense areas in pancreas. He was reviewed by Dr. .Kumaresan on 24.1.1996 and CT scan of brain was taken. He developed headache on 24.1.1996 and had neck stiffness. Lumbar puncture was done by Dr. Kumaresan on 27.1.1996. This showed deared CS fluid. Some treatment continued. On 29.1.1996, patient was reviewed by Dr. Kumaresan and he opined that due to rise of CSF protein, anti-TB treatment should be continued. On 30.1.1996, patient became drowsy and • had difficulty in breathing. He was shifted 'to opposite party No. 7-St. Isabel Hospital. On 31.1.1996, he was seen by Dr. Kumaresan and Dr. A. V. Srinivasan, M.D., D.M. Neurology. He was given necessary supportive treatment but he died on 3.2.1996. It was further stated that the records would show that Naveen Kant had • a successful kidney transplant and was managed with utmost care at Aswini Soundra Hospital-opposite party No.6. Isabel Hospital. On 31.1.1996, he was seen by Dr. Kumaresan and Dr. A. V. Srinivasan, M.D., D.M. Neurology. He was given necessary supportive treatment but he died on 3.2.1996. It was further stated that the records would show that Naveen Kant had • a successful kidney transplant and was managed with utmost care at Aswini Soundra Hospital-opposite party No.6. He did not have forearm pain or any other evidence of infection at the time of discharge from there. Cellulitis left forearm and fever had developed on the 18th postoperative day, namely 6 days after discharge: After discharge he was promptly started on aggressive antibiotic therapy. Since fever persisted he was admitted to opposite party No. 4-K.S. Hospital where he had an episode of transient seizure. An eminent neurologist was consulted and antibiotics were continued as indicated above. Despite exhaustive and aggressive anti-biotic therapy the fever of Naveen Kant persisted and there was mild persistent induration in the left forearm. Repeated blood, urine and pus cultures failed to reveal any organism even though Naveen Kant continued to have fever. Opinion of an experienced chest physician was sought and anti-TB treatment was started and continued as per his advice. In spite of all prompt, aggressive and modem care the exact cause of Naveen Kant's fever could not be identified. Culture for bacteria and fungi were repeatedly negative. Suppressive therapy also predisposes to various opportunistic infections, the exact nature of which is often difficult to establish. It was denied that there was any negligence/deficiency in post operative treatment of Naveen Kant as alleged. It was further stated that to provide post-operative treatment after kidney trans-plantation surgery the hospitals need not be registered under the Transplantation of Human Organs Act, 1994 and Rules made there under. Opposite party Nos. 4 . and 7 were not statutorily debarred from commencing any activity rotating to follow-up medical care to the persons who have undergose transplantation. 3. In their separate replies, opiate parties Nos. 2 and 5 adopted the reply filed by opposite party No.1. 4. Opposite party No.6 filed reply on the affidavit of its proprietor-Dr. Sadayavel, Kailasam. It was alleged that opposite party No.6 is a reputed nursing home and has infrastructural facilities to undertake major surgeries. It is registered under the Transplantation of Human Organs Act, 1994. 2 and 5 adopted the reply filed by opposite party No.1. 4. Opposite party No.6 filed reply on the affidavit of its proprietor-Dr. Sadayavel, Kailasam. It was alleged that opposite party No.6 is a reputed nursing home and has infrastructural facilities to undertake major surgeries. It is registered under the Transplantation of Human Organs Act, 1994. Several kidney transplant operations have been successful); done in opposite party No.6-nursing home Naveen Kant was a patient of opposite party No.1. He underwent kidney transplant operation in opposite party No. 6nursing home and surgery was carried out by opposite party Nos. 5 and 1 with utmost care and expertise and renal transplantation was successful on 12.11.1995. ICU was kept sterile and clean to avoid any kind of infection. After Naveen Kant developed fever on 14.11.1995 he was given Fortum injection and tablet Novaquine. There was no complaint of forearm pain. As an abundant caution routine antibiotics were administered to him to prevent any infection. Naveen Kant was discharged in good condition. On 24.11.1998 there was no fever or forearm pain or any tenderness. Infection would have contacted while Naveen Kant was at his house after discharge from opposite party No.6-nursing home. Allegation of deficiency in service on the part of opposite party No.6-nursing home was denied. 5. Opposite party No.7-hospital filed reply. It was alleged that on 31.1.1996 Naveen Kant was admitted in unconscious and critical condition. There was no lack of care on the part replying opposite partyhospital. In the additional reply, it was stated that Section 10 of the Act of 1994 does not include follow-up care and the complainants have roped in the answering opposite party unnecessarily. 6. Opposite party Nos. 3. and 4 in their reply denied the allegations of medical negligence/deficiency in service as alleged. 7. We heard the parties' learned Counsel. Written arguments have also been filed on behalf of the complainants and opposite parties Nos. 1, 2,5 and 6. 8. By way of evidence the complainants filed the affidavits of complainant No.1, Mrs. Vimla Akhouri; Dr. (Mrs.) Mini Rani Dutta and two expert witnesses-Col. (Dr.) Ashok Chopra and Dr. (Mrs.) Sophia Ahmed. In her affidavit, complainant No. 1 has by and large supported the averments made in complaint. Mrs. 1, 2,5 and 6. 8. By way of evidence the complainants filed the affidavits of complainant No.1, Mrs. Vimla Akhouri; Dr. (Mrs.) Mini Rani Dutta and two expert witnesses-Col. (Dr.) Ashok Chopra and Dr. (Mrs.) Sophia Ahmed. In her affidavit, complainant No. 1 has by and large supported the averments made in complaint. Mrs. Vimla Akhouri whose husband is the first cousin of complainant No.1, averred that on 7.1.1996 opposite party No.1 admitted to her that Naveen Kant was in advanced stage of septicaemia. Dr. (Mrs.) Mini Rani Dutta, sister of complainant No.1, supported the affidavits of said two expert doctors. In his affidavit, Col. (Dr.) Chopra, MBBS, MS in General Surgery, inter alia, averred that he took his release from army in the year 1997 and has been doing consultancy services in BSES hospital at present. He examined the records and the papers made available to him. After successful kidney transplant operation on 12.11.1995, opposite party Nos. 1 and 5, since the commencement of post-operative care and opposite party Nos. 2 and 3 a bit later, failed to control and treat infection that had manifested itself in the form of persistent pain in the left forearm of Naveen Kant at the site where needle was inserted for injection of drugs and fluids in the ICU of opposite party No. 6nursing home. Onset of fever' and chill on 14.11.1995, two days after transplant operation and urinary catheter growing Klebsiella on 17.11.1995 when Naveen Kant was still in ICU of opposite party No.6-nursing home were two major signals which should have alerted the treating doctors that there was infection to be urgently addressed. However, these signals were not taken seriously. Test report dated 23.11.1995 (copy at page 209) showed high total leucocyte count (TLC was 25,900 as against the normal range of 3000-11000). Haematology report dated 24.11.1995 (copy at pages 85 to 86) showed 87% of polyrilorphs against a normal range of 55% to 65%. These taken together make it obvious that Naveen Kant was discharged from opposite party No.6-hospital on 24.11.1995 with infection still in his body. He further averred that appearance of cellulitis on 30.11.1995 in the left forearm with fever did not rule out existence of infection from before. Treatment of Naveen Kant as out patient from 24.11.1995 to 18.12.1995 did not result in improvement in his condition. He further averred that appearance of cellulitis on 30.11.1995 in the left forearm with fever did not rule out existence of infection from before. Treatment of Naveen Kant as out patient from 24.11.1995 to 18.12.1995 did not result in improvement in his condition. KS Hospital-opposite party No.4 was not registered under the Transplant of Human Organs Act, 1994 and the Rules made there under. During his stay at .KS hospital-opposite party No.4 due to omissions and commissions of opposite parties, the infection far from being controlled was allowed to run rampant in the body of Naveen Kant and his condition became bad to worse 30.1.1996. It was further stated that after re-hospitalisation of Naveen Kant on 21.12.1995, opposite party No. 1 abruptly became unavailable from 23.12.1995 to 30.12.1995 In opposite party No.4-hospital, Naveen Kant was given injection Fortum and Amikacin since 21.12.1995. Even though after a lapse of more than 72 hours his fever was not subsiding, these medicines were continued. Giving all these antibiotics worsened the condition of Naveen Kant. Circumstances warranted review of the efficacy of these medicines. Ultrasonogram report dated 26.12.1995 (at page No. 108) indicated four hypodese spots in the pancreas of Naveen Kant snowing spread of infection to his vital organs. One daily dose of Amikacin was inadequate and ought to have been doubled. Injection Amikacin 400 mg. was started twice daily from 5.12.1995 to 12.12.1995 and again from 6.1.1996 to 12.1.1996. It was not understandable why from the date of hospitalization the dose of Amikacin was halved and continued to be so till 29.12.1995. This contributed to the spread of infection unchecked. Intravenous injection of Metrogyl and Cifran LV. as suggested by Dr. Mini Dutta would have been more efficacious compared to oral administration. There was no attempt to take repeated samples at frequent intervals of the blood and sputum for culture in order to find out the causative micro-organism responsible for infection. Lumbar puncture and CSF examination should have been done one month earlier after the patient had headache, giddiness followed by unconsciousness on 21.12.1995 in KS. hospital-opposite party No.4. CSF report at pages 147 and 149 clearly indicated Pyogenic Meningitis. He admitted that as a Nephrologist, the opposite party No. 1 is well qualified and obviously has a reputation. Lumbar puncture and CSF examination should have been done one month earlier after the patient had headache, giddiness followed by unconsciousness on 21.12.1995 in KS. hospital-opposite party No.4. CSF report at pages 147 and 149 clearly indicated Pyogenic Meningitis. He admitted that as a Nephrologist, the opposite party No. 1 is well qualified and obviously has a reputation. Had the drainage of abscess been carried out by at least three weeks earlier instead of on 23.12.1995 there would have been no ocassion of Naveen Kant deteriorating and finally losing his life. This witness and Dr. Sophia Ahmed were allowed to be cross-examined by serving interrogatories by the opposite parties. In answer to the following questionnaires for cross-examination on behalf of opposite parties Nos. 1, 2,5 and 6, Col. Chopra stated : Q-2 Have you conducted any Renal Transplant Surgery in the past? A. No. But I have conducted numerous types of surgeries including surgical procedures relating to the kidneys. I have wide experience in operative and post operative surgical procedures. The basic principles of surgery are the same. Q-15 Have you perused the hospital records produced by opposite parties 1,2,5 and 6? A. Yes. I have subsequently seen the hospital records produced by opposite party Nos. 1, 2, 5 and 6 which have been made available finally in May, 2004. Q-17 Can you say whether there is any recording about the forearm pain while in the hospital before discharge? A. The hospital records of opposite party No.6 are significantly silents with regard to any complaint or observation with regard to the patient. It is a normal practice to record such observations in the case sheets/daily observations chart. Merely because there is nothing recorded in the case sheet does not permit the opposite parties to say that there was no complaint of the pain in the left forearm. The subsequent events, namely, in duration, cellulitis and abscess indicate that the patient's left forearm had suffered some injury or damage. Any reasonable person would have expressed the same to the Doctors and Nurses, who have obviously not given it sufficient attention. Q-34 From the clinical, microqiological and ultrasound reports, can you find any evidence of infection, at the time of discharge from Aswini Soundra Nursing Home? A. Yes, there is evidence of infection from the following : (i) High TLC in the report dated 23.11.1995 (page 209). Q-34 From the clinical, microqiological and ultrasound reports, can you find any evidence of infection, at the time of discharge from Aswini Soundra Nursing Home? A. Yes, there is evidence of infection from the following : (i) High TLC in the report dated 23.11.1995 (page 209). (ii) High Polymorphs in the report dated 24.11.1995 (pages 86-88). (iii) Cellulitis and appearance of abscess on the patient's left forearm were noted by opposite party No, 1 on 30.11.1995. This does not rule out the existence of infection at that site at the time of the patient's discharge from hospital on 24.11.1995. Q-36 Kindly peruse the hospital records of opposite party Nos. 1,2,5 and 6. A. I have perused the hospital records. Q-37 Now, do you agree that urine culture was negative and there was no fever? A. Yes. But that does not detract from the validity of my critique in paragraphs 7 to J 1 and 18 and 20 of my affidavit of evidence dated 2.1.2004. Q-41 Can you admit from the records that cellulitis was found only on 30th November, 1995 i.e. after 14 days of stoppage of IV FLUIDS (16.11.1995)? A. No. While the existence of cellulitis may have been recorded for the first time only on 30.11.1995, it cannot be said that "it was found" for the first time on that date. Cellulitis is not an overnight development. It was obviously festering and was ultimately recorded by opposite party No.1 only on 30.11.1995. Q49 What may happen if AMIKACIN is continued after 7 days? A. If injection Amikacin is continued after 7 days, it is likely to damage the kidneys of the patient because Amikacin is a potential nephrotoxic agent. Q-52 Please refer page 97. Do you admit that the pus lab test revealed negative and revealed no growth in culture? A. Yes. However, if the pus specimen shows negative in quality that, by itself, does not mean that there is no infection. Q-103 Are you aware that Leucocytosis may occur in post-transplant patients without any evidence of infection? A. Yes. However. these blood cells count come back to normal after 24 hours of the administration of Corticosteroids. Q-114 As per case records do you agree that the following medicines were administered to the patient during the period 12.11.1995 to 3.2.1996 depending upon the condition that prevailed during the relevant time? A. Yes. However. these blood cells count come back to normal after 24 hours of the administration of Corticosteroids. Q-114 As per case records do you agree that the following medicines were administered to the patient during the period 12.11.1995 to 3.2.1996 depending upon the condition that prevailed during the relevant time? Q-115 Injection Amikacin and Reflin on 12.11.1995 (during surgery) (a) Injection Reflin 12.11.1995 to 14'.11.1995. (b) Injection 14.11.1995. (c) Nivaquin 14.11.199-5 to 16.11.1995, 18.12:1995 to 22.12.1995, 23.1.1996 to 27.1.1996. (d) Injection Ciprofloxacin 20.11.1995 to 27.11.1995. (e) Injection Reflin 30.11.1995 to 4.12.1995. (f) Injection Amikacin 5.12.1995 to 12.12.1995, 21.12.1995 to 28.12.1995, 3.1.1996 to 13.1.1996. (g) Injection Cirpofloxacin 5.12.1995 to 15.12.1995. 27.12.1995 to 2.1.1996. (h) Injection Vancomicin 16.12.1995, 28.12.1995 to 3.1.1996. (i) Injection Fortum 21.12.1995 to 28.12.1995, 6.1.1996 to 14.1.1996. (j) Injection 24.12.1995. Mefloquin (k) Injection Metrogyl 27.12.1995 to 3.1.1996. (I) Injection Rifampicin inh Ethambutol 29.12.1995 to 2.1.1996, 12.1.1996 to 3.2.1996. (m) Injection Aztreonom 3.1.1996 to 5.1.1996, 9.1.1996 to 14.1.1996, 16.1.1996 to 3.2.1996. A. I do not agree that the medicines were administered to the patient as stated in the question or that they were adequate. The question itself contains various errors which are as follows : (a) No injection of Amikacin on 12.11.1995 (during surgery)- see page 16 of record of Aswini Soundra Nursing Home (ASNH)-opposite party No.6. (b) ................. (c) ................. (d) No Nivaquin 23.1.1996 to 27.1.1996. It was Chloroquin Tab. (see KS hospita records) (e) No injection Ciprofloxacin 20.11.1995 to 27.11.1995. It• was only tablets (see ASNH's records, pages 33, 35, 37, 39, 41 and 93). (f) ................ (g) Injection Amikacin 5.12.1995 to 12.12.1995 B.D. i.e. twice daily; 21.12.1995 to 28.12.19950.0. Le. once daily 3.1.1996 to 13.1.1996: B.D. (h) No Injection Ciprofloxacin 5.12.1995 to 15.12.1995, 27.12,1995 to 21.1.1996. Only tablets Cifran 500 mg. B.D. (i) Injection Vancomycin (Vancocin) 16.12.1995, (one dose only), 29.12.1995 to . 3.1.1996. (j) Injection Fortum 21.12.1995 to 28.12.199,5,6.1.1996 to 13.1.1996. The record for 14.1.1996 shows that Injection Fortum was struck off and discontinued' (see KS. Hospital records). (k) No injection Mefloquin. 24.12.1995. Only tablets on 24.12.1995 and 25.12.1995. (l) No injection Metrogyl 27.12.1995 to 3.1.1996. Only tablet from 27.12.1995 to 2.1.1996. (m) No injection Rifampicin inh Ethambutol 21.12.1995 to 1.1.1996, 12.1.1996 to 3.2.1996 only tablets. (n) Injection Aztreonom 2.1.1996 to 5.1.1996, 9.1.1996 to 13.1.1996, 16.1.1996 to 22.1.1996. After perusing the hospital record subsequently produced by opposite party Nos. 24.12.1995. Only tablets on 24.12.1995 and 25.12.1995. (l) No injection Metrogyl 27.12.1995 to 3.1.1996. Only tablet from 27.12.1995 to 2.1.1996. (m) No injection Rifampicin inh Ethambutol 21.12.1995 to 1.1.1996, 12.1.1996 to 3.2.1996 only tablets. (n) Injection Aztreonom 2.1.1996 to 5.1.1996, 9.1.1996 to 13.1.1996, 16.1.1996 to 22.1.1996. After perusing the hospital record subsequently produced by opposite party Nos. 3 and 4 on 29.12.2003 in relation to the K.S. Hospital and by opposite parties Nos. 1,2,5 and 6 on 6th May, 2004 in relation to the ASNH confirms that the medicines were not administered in the requisite potency or dosage. The patient was not administered the requisite medicines by proper route i.e. they were administered orally when they ought to have been given parenterally/intravenously. Q.117 Do you agree that the choice of antibiotics in a given patient would depend on (a) Efficacy as determined by local antibiotic sensitivity data, (b) probable toxic effects, and (c) Affordability (sic) of the patient to bear the cost of medium? A. I would agree with factors (a) and (b). I do not see how factor (c) arises in this case as it seems whatever medicines were prescribed they were duly purchased by the complainant No.1. Q.136 Are you aware after going through records that on 14.11.1995 fever and chill was only due to malaria and it responded to anti-malarial treatment with no further rise in temperature? A. After going through the records of Aswini Soundara Nursing Home, opposite party No.6, which were made available to the complainants in May, 2004 and then to me, I state that it is wrong to say that the patient's febrility on 14.11.1995 was only due to . malaria and that it responded only to malarial treatment. The records that both on 14.11.1995 and 15.11.1995. not only Nivaquine for anti-malarial treatment but also injection Fortum for antibacterial, anti-infection treatment was administered. Therefore, it cannot be presumed that the patient's fever on these dates was only due to malaria and not due to any other Nosocomial infection. Moreover, it is fallacious to say or assume that the subsidence of the patient's fever on and after 16.11.1995 was indicative of the infection being controlled. Therefore, it cannot be presumed that the patient's fever on these dates was only due to malaria and not due to any other Nosocomial infection. Moreover, it is fallacious to say or assume that the subsidence of the patient's fever on and after 16.11.1995 was indicative of the infection being controlled. On the contrary, the records of opposite party No. 6 now produced (vide page 13) shows that during the patient's stay in the hospital the total leucocyte count remained at abnormally high levels dearly indicating the persistence of the nosocomial infection. The records evidence the rise in the patient's TLC as follows- 11.11.1995 8,100 12.11.1995 - 13.11.1995 22,050 14.11.1995 16,600 15.11.1995 11,600 16.11.1995 12,700 17.11.1995 19,050 18.11.1995 20,000 20.11.1995 28,900 21.11.1995 32,400 22.11.1995 20,550 23.11.1995 25,900 Q.137 Are you aware that Klebsiella infection of the urinary catheter was treated with ciprofioxacin from 20.11.1995 to 27.11.1995 to which the organism was sensitive? A. Yes Q.138 Are you aware that the urine culture was subsequently negative (22.11.1995)? A. The question, as posed to me, is misleading and self-contradictory, especially in the light of the preceding question 137. Since the patient was admittedly being treated with Ciprofioxacin from 20.11.1995 to 27.11.1995 for the Klebsiella found in the urinary catheter, there could be no question of the urine culture being "subsequently" negative on 22.11.1995. Secondly, questions 137 based on the records itself shows that the patient was being treated with the antibiotic Ciprofioxacin from 20.11.1995 to 27.11.1995•and hence the urine culture on 22.11.1995 was bound to show negative. What question Nos. 137 and 138 do not touch upon is that, no urine culture was done after 27.11.1995, when Ciprofioxacin was discontinued. Q. 139 Was there any fever as per the records at the time of discharge (24.11.1995)? A. No. 9. In response to, question No.9 put on behalf of the opposite party Nos. 2 and 3 the witness replied: Q.9 Whether opposite party Nos. 3 and 4 are responsible for the causation of infection? A. Dr. KK Bhatt, Resident Medical Officer, KS. Hospital, opposite party No.3 may not be responsible for causation of the infection in the patient. In response to, question No.9 put on behalf of the opposite party Nos. 2 and 3 the witness replied: Q.9 Whether opposite party Nos. 3 and 4 are responsible for the causation of infection? A. Dr. KK Bhatt, Resident Medical Officer, KS. Hospital, opposite party No.3 may not be responsible for causation of the infection in the patient. But that does not absolve them of responsibility for exercising due care and caution and rendering efficacious and timely treatment to the patient once they accepted and admitted the patient on 21.12.1995, and partly so, since they had noted and recorded his history and condition at the time of admission. 10. In her affidavit, Dr. Sophia Ahmed, MBBS and holding a Board Certification in Neurology from the American Board of Psychiatry and Neurology averred that high leucocyte count of Naveen Kant as on 23.11.1995, i.e. the 11th post-operative day, was certainly indicative of latent infection. This significant index was ignored while discharging the patient the very next day i.e. 24.11.1995. Even after discharge the patient had been visiting opposite party No. 1 in the clinic on regular basis. On 30.11.1995, opposite party No.1 noted that Naveen Kant had fever and cellulitis/abscess L.T. Forearm. This was the site where Naveen Kant had been complaining of pain right from the time when, he was in ICU according to complainants. Cellulitis is the first stage of infection under the skin which culminates in abscess, if untreated. Cellulitis would occur "if there is drainage, an open wound, or an obvious portal of entry". Cellulitis/abscess as recorded by opposite party No. 1 on 30.11.1995 in his clinical notes had its onset prior to the patient's discharge from the hospital on 24.11.1995. Naveen Kant had contacted a nosocomial infection in his left forearm when he was in care and custody of opposite party Nos. I, 2,5, and 6 and the opposite parties did not address the infection with the urgency, potency and seriousness that it deserved in the case of an immuno suppressed patient. Opposite party No.1 on 30.11.1995 prescribed only Reflin injection. He should have been well aware that Ret1in is a Cefazolin and a first generation Cephalosporin which is not recommended as a first choice in such patients. After the burst on 2.12.1995. Opposite party No.1 on 30.11.1995 prescribed only Reflin injection. He should have been well aware that Ret1in is a Cefazolin and a first generation Cephalosporin which is not recommended as a first choice in such patients. After the burst on 2.12.1995. opposite party No. 1 should have advised hospitalization of Naveen Kant and by prescribing injedion Amikadn and tablet Quintor the dodor displayed a complacency that constitute negligence espedally vis-a-vis an organ transplant immuno suppressed patient. He further averred that on 12.12.1995, opposite party No.1 issued a detailed final prescription whereby he relieved the patient from continuing to visit him. Naveen Kant was prescribed a single dose of Vanwmydn for probable staph infedion. Opposite party No. 1 left Naveen Kant un coovered on and from 17.12.1995. He prescribed him a single dose of Vanwmydn which exhausted itself on 17.12.1995. On 23.12.1995, opposite party No. 1 left the town without seeing Naveen Kant and he was away upto 30.12.1995. Ultrasound of Naveen Kant done on 26.12.1995 revealed abscess in the pancreas which clearly indicated that the infection had spread to the pancreas. Lumbar puncture done on 24.1.1996 was highly belated. There was negligence on the part of opposite parties in treating Naveen Kant. 11. In answer to the questionnaire on behalf of opposite party Nos. 1,2,5 and 6 the witness stated: Q.8 Do you accept that the Renal Transplantation Surgery itself is a specialty, which needs special skill and training? A. Yes. Q.16 Do you agree that medicines have to be introduced /continued / discontinued / altered according to the response by the patient? A. Yes. More importantly, the condition of an organ transplant patient, particularly in the immediate post-operative period, must be monitored continuously and appropriate medicine must be prescribed and administered in a timely manner, in appropriate dosage and by the proper route. Q.17 Have you perused the hospital records produced by the opposite parties 1,2,5 and 6? A. Yes. As explained in answer to question No. 7 above, no hospital records were produced by opposite party Nos. 1,2,5 and 6 as on the date of my deposition/ affidavit of evidence, namely, as on 17th December, 2003. Q.17 Have you perused the hospital records produced by the opposite parties 1,2,5 and 6? A. Yes. As explained in answer to question No. 7 above, no hospital records were produced by opposite party Nos. 1,2,5 and 6 as on the date of my deposition/ affidavit of evidence, namely, as on 17th December, 2003. Even thereafter, though the said records are supposed to have been filed on 3.2.2004, the said opposite parties had not made copies of the said records available to the complainants till 6.5.2004 and, hence, they have been made available to me for perusal only now. Q.19 Can you say whether there is .any recording about the forearm pain while in the hospital before discharge? A" This question aSS1,.lmes that opposite party Nos. 1, 2, 5 and 6 had produced the records of 'Aswini Soundra Nursing Home' as on the date of my deposition viz. 7.12.2003. In fact, they had not done so. I have adverted to this aspect in paragraph 12.7 of my affidavit of evidence dated 17th December, 2003. Now that I have the benefit of perusing the records of ASNH, opposite party No.6, I notice a singular and marked omission throughout the case sheet and report chart as well as the daily observation on chart of the patient (see pp.11.41,42.68 of the compilation of the ASNH Hospital records). Significantly, on no day do the case sheet or charts record whether the patient has any complaint, and if so, what? Indeed the case sheet and the charts do not even record that the patient has no complaint or that 'he has no new complaint. It is firmly established and invariable medical practice that either of these things is recorded in the case sheet and treatment/daily observation charts of the patient. Therefore, it does not avail the opposite parties to say that the patient, made no complaint of pain in his left forearm merely because it has not been recorded in the case sheet and report charts by the attending doctors. On the other hand, the subsequent indurations, then cellulitis and then abscess that admittedly developed in the patient's left forearm are clear pointers that the patient must have suffered pain in that region. Hence it is reasonable to infer that he must have articulated it to the attending doctors and nurses. On the other hand, the subsequent indurations, then cellulitis and then abscess that admittedly developed in the patient's left forearm are clear pointers that the patient must have suffered pain in that region. Hence it is reasonable to infer that he must have articulated it to the attending doctors and nurses. By definition, pain is a necessary concomitant of in duration cause by inflammation that evidences cellulitis and later abscess. According to Bailey and Love's Short Practice of Surgery, 22nd Edition, 1995, for instance: "Cellulitis is inflammation of tissues, usually superficial or subcutaneous tissue. The part affected is swollen, tense and tender. Later it becomes red, shiny and boggy. It may progress to abscess which is the presence of pus in the tissue concerned. Inflammation which is the earlier stage of cellulitis, is the presence of redness, swelling, heat and tenderness, often associated with the loss of function". It is highly surprising that as on 30.11.1995, Dr. Muthusethupathy, opposite party No. 1, observes and records fever, cellulitis/ abscess in the patient's left forearm and yet records no complaint of pain by the patient. See further my answer to question No. 116 below. I am inclined to believe, therefore, that the patient must have complained of pain in the left forearm to the attending doctors and nursing staff but they did not give it the attention it deserved. Q. 21 Can you say that the patient was not given any medicine at all to control the infection. If you say yes, how do you say so without perusing the records? A. This question assumes and attributes to me a statement that I have never made. I have nowhere stated in my deposition dated 17th December, 2003 that the patient Naveen Kant was not given any medicine at all to control the infection. On the other hand, what I had deposed is that the requisite and appropriate medicines were not prescribed or administered timely and not changed when found ineffective, not administered parenterally/intravenously but orally, and not in correct or optimum dosage. In this behalf, I reaffirm and reiterate my deposition in paragraph 12.7 onwards of my affidavit of evidence dated 17th December, 2003. Q. 34 Do you agree that as per the hospital records the condition of the patient was completely normal. when he was discharged from the hospital of opposite party No. 6? In this behalf, I reaffirm and reiterate my deposition in paragraph 12.7 onwards of my affidavit of evidence dated 17th December, 2003. Q. 34 Do you agree that as per the hospital records the condition of the patient was completely normal. when he was discharged from the hospital of opposite party No. 6? A. No, I disagree most emphatically that the condition of the patient was completely normal when he was discharged from hospital opposite party No.6. Significantly, despite the Hon'ble Commission's order dated 23.1.2002 directing the opposite parties to submit the hospital records of the treatment of the deceased patient, within 12 weeks from that date, opposite parties Nos.1, 2,5 and 6 did not produce or file the said records even as at 17th December, 2003, when I deposed on affidavit by way of evidence. As it transpires, they filed the said records only on 3.2.2004 and that too without furnishing copies to the complainants. Even now, the questions dated 12.3.2004 being put to me do not specify or confront me with any part of those medical records. Q. 38 From the clinical, microbiological and ultrasound reports can you find any evidence of infection, at the time of discharge from Aswini Soundra Nursing Home? A. Yes, I find ample evidence of infection, for the following reasons-The clinical reports (pp.8.10,11.41 and 42.68 of the compilation dated 6.5.2004 filed by opposite party Nos. 1,2,5 and 6) are significantly incomplete. They do not record the patient's complaints. There is no clinical assessment of the patient recorded. In other words, throughout there is no recording of the subjective condition of the patient (see e.g. the clinical notes starting from 12.11.1995 at pages 17,19,21,23,24,26, 28, 30, 32, 34,36,38 and 40). These are the case sheets of the patient's renal transplant from 12.11.1995 to 24.11.1995 with the clinical notes of Dr. Muthusethupathy opposite party No.1. Even the daily observation charts of the patient for this period do not record the patient's complaints or even that the patient has no complaints or no new complaints. (At best they only record the attending doctors nurses remarks that Dr. Muthusethupathy was contacted and informed about the patient's condition, without disclosing as to what precisely was the patient's condition (see pages 42 to 68 of the same compilation). Medically, it is impossible for such a patient, who has undergone such a major surgery, not to have any complaint. (At best they only record the attending doctors nurses remarks that Dr. Muthusethupathy was contacted and informed about the patient's condition, without disclosing as to what precisely was the patient's condition (see pages 42 to 68 of the same compilation). Medically, it is impossible for such a patient, who has undergone such a major surgery, not to have any complaint. Among other things, the manifestation of the in duration, cellulitis and abscess on 30.11.1995 in the patient's left forearm leaves no room for doubt that the patient must have suffered pain in that region. The omission or failure of opposite parties Nos. 1, 2, 5 and 6 and their assistant medical and nursing staff to record the patient's clinical condition does not mean that the patient had not contracted and was not suffering from a nosocomial infection. As regards the microbiological reports, the blood reports shows that on 13.11.1995 (48 hours after Cortico Steroid Therapy was started and immediately after surgery) the patient's total white' cell count rose from 8100 cells/cu. mm on 11.11.1995 to 23050 cells/cu. mm on 13.11.1995. The normal range is 8000 to 12000 cells/ cu.mm. After this initial rise the total cell count fell to 16,900 cells/cu. mm. on 14 11.1995. then to 11,600 cells/cu. mm. on 15.11.1995 and then to 12,700 cells/cu. mm on 16.11.1999. In other words, within 72 hours of the initial rise, the patient's total cell count had returned to near normal. As I have pointed out in paragraph 12.4 of my affidavit with citations of medical authority, in a patient who is administered Cortico Steroids, there is initial increase in the total white blood cell counts. But these blood cell counts return to normal after 24 hours. However, the report chart of the patient in the present case shows that on 17.11.1995 his total cell count shot up to 19,050 cell/cu. mm. and remained consistently high and continued to rise progressively thereafter, viz., 20,000 cells/cu. mm on 18.11.1995,28,900 cells cu. mm on 20.11.95, 32,400 cells/ cu. mm. on 21.1.1995, 20,550 cells/cu. mm. on 22.11.1995 and 25,900 cells/cu.mm. on 23.11.1995. It is in this condition) that the patient was discharged on 24.11.1995. All throughout he was being administered Cortico Steroids. mm. and remained consistently high and continued to rise progressively thereafter, viz., 20,000 cells/cu. mm on 18.11.1995,28,900 cells cu. mm on 20.11.95, 32,400 cells/ cu. mm. on 21.1.1995, 20,550 cells/cu. mm. on 22.11.1995 and 25,900 cells/cu.mm. on 23.11.1995. It is in this condition) that the patient was discharged on 24.11.1995. All throughout he was being administered Cortico Steroids. Thus, the total cell count data unmistakably shows that from 17.11.1995 onwards a new pathology had developed in the patient's condition that was clearly indicative of an underlying infection (see page 13 of the compilation). Yet, opposite parties Nos. 1,2,5 and 6 made no. efforts to ascertain the etiology of the infection. No blood culture was done even after seeing• this ominous change. In my opinion, the persistence of the patient's elevated total leucocytes count on and after 17.11.1995 till the time of his discharge on 24.11.1995 was ample evidence to show any infection. At best, it is used to visualize gross anatpmy and pathology and is not expected to reveal any micro-pathology. Q.59 Please refer page ,97. Do you admit that the pus lab test revealed negative and revealed no growth in culture? A. Yes. The test report dated 9.12.1995 of the Renal Laboratory of K.S. Hospital, opposite party No.4, showed that when the patient's pus specimen was sent for culture, it revealed "no growth in culture". However, it is significant that the report does not disclose the date of receipt of the specimen sent for pus culture by the Renal Laboratory. Moreover, there is no evidence of collection of the pus specimen on 6.12.1995 or 7.12.1995. The matter should not have been left at that. In any event, even if a pus specimen turns out negative on culture that does not mean necessarily that there is no infection. Q. 96 Are you aware that when the patient developed fever, blood culture, urine culture and blood for malaria parasite was done, periodically? A. Yes, but the culture was not done in accordance with established practices. Repeated specimens of urine and blood taken frequently on the same day should have been sent for culture to identify the causative organism for infection. There was complete failure on this score. Q.98 Are you aware that Leucocytosis may occur in post-transplant patients without any evidence of infection? A. Yes, there IS a transient rise in" the white blood cell counts in post-transplant patients. There was complete failure on this score. Q.98 Are you aware that Leucocytosis may occur in post-transplant patients without any evidence of infection? A. Yes, there IS a transient rise in" the white blood cell counts in post-transplant patients. I have already deposed in paragraph 12.4 of my affidavit of evidence with citations and supporting medical authorities that these blood cell counts come back to normal after 24 hours of the administration of Cortico Steroids. Q.104 Do you agree that after anti-ma, larial therapy, the patient's temperature remained normal from 7 p.m. on 14.11.1995 till the time of discharge on 24.11.1995? A. I - do. not agree that the anti malarial therapy by itself accounted for the patient's temperature remaining near about normal from 7 p.m. on 14.11.1995 till the time of discharge on 24.11.1995. I find from the records now produced (long after my deposition/affidavit of evidence) that the patient had been started on an antibiotic, injection Fortum, from the night at 11 p.m. on 13.11.1995. The antibiotic too would have helped regulate and stabilize the patient's temperature around normal. Q.105 Do you agree that after even the patient's temperature remained normal, he was started in Ciprofloxacin, to treat the Klebsiella grown from the Foley catheter tip and that Ciprofloxacin was given from 21.11.1995 till 27.11.1995? A. Yes. I agree that even though the patient's temperature was around normal, he was started on another antibiotic, Ciprofloxacin 500 mg. tab. From 21.11.1995 onwards, till 27.11.1995 Le. till even after his discharge on 24.11.1995. This course of treatment itself establishes certain. facts. In the first place, it is evident that despite the temperature hovering around normal between 14.11.1995 and 24.11.1995, the patient nevertheless had developed an infection. Secondly, the infection contracted was nosocomial, that is to say, while the patient was still in the ICU and in the care of opposite parties Nos.1, 2, 5 and 6. Thirdly, the infection persisted even as on 24.11.1995 when the patient was discharged from hospital. This is precisely the point I had made in paragraph 8 cmwards of my affidavit of evidence dated 17th Decmeber, 2003, even without the benefit of the medical records now furnished on 6th May, 2004 to Counsel for the complainants by Counsel for opposite parties Nos. 1,2,5 and 6. These records now confirm and reinforce what I had already stated. This is precisely the point I had made in paragraph 8 cmwards of my affidavit of evidence dated 17th Decmeber, 2003, even without the benefit of the medical records now furnished on 6th May, 2004 to Counsel for the complainants by Counsel for opposite parties Nos. 1,2,5 and 6. These records now confirm and reinforce what I had already stated. Q.108 Are you aware that the patient at the time of discharge is instructed to maintain temperature chart every 4th hourly with his own thermometer and maintain fluid intake and urine output chart daily? A. Yes. But I have not seen any such instructions in writing. Q.117 Whether from hospital records, was there any symptoms such as pain, swelling, in duration noted in the case sheet till the time of discharge? A. It does not appear from the hospital records of ASNH, opposite party No. 6, now made available that any symptoms such as pain, . swelling, in duration were noted in the case sheet of the patient till time of his discharge on 24.11.1995. However, the omission to record does not mean the absence of such symptoms. As have already explained in paragraph 12.7 of my affidavit of evidence, the subsequent developments and manifestation of cellulitis and abscess in the patient's left forearm relate back to the patient's nosocomial infection. Opposite party Nos. 1,3 and 5, Dr. Sadayavel Kailasam, proprietor of opposite party No. 6-nursing home, Dr. S. Anna Mathew and Dr. S. Venkatesan on behalf of opposite party No.7 filed affidavits of evidence. Affidavits of Dr. K.S. Mathur and Dr. S. Sunder, expert witnesses were also filed on behalf of opposite party Nos. 1, 2, 5 and 6. Deponents of the affidavits who supported the stand taken in the reports, were permitted to be cross-examined by the complainants on interrogatories. Questions put to opposite parties Nos. 1 and 5 in cross-examination and the depositions of said two expert witnesses only need to be referred to in detail to decide this case. In reply to the following questionnaire, Dr. Muthusethupathy, opposite party No. 1 replied thus: Q. 2 In the concluding paragraph (Paragraph 31) of your Affidavit of evidence, you have deposed that you are "Also relying upon the documents filed in support of the case if the opposite parties which also be read as part and parcel of this affidavit". In reply to the following questionnaire, Dr. Muthusethupathy, opposite party No. 1 replied thus: Q. 2 In the concluding paragraph (Paragraph 31) of your Affidavit of evidence, you have deposed that you are "Also relying upon the documents filed in support of the case if the opposite parties which also be read as part and parcel of this affidavit". The record shows that as on 21st July, 2002, the date of your deposition and also as on the date of this questionnaire, no document whatsoever have been filed in support of the case of opposite party Nos. 1, 2 and 5. Please specify which are the documents to which you refer in your said statement? A. Para 10 (not 31) of my affidavit refers to the case sheet, Nurses record and drug charts of Mr. Naveen Kant during his stay in the Post Renal transplantation room of Aswini Soundra Nursing Home. These records have already been filed before the Hon'ble Commission on 3.2.2004 by our Counsel. I have referred to only those records mentioned above. Q. 3 Do you agree that the following medical records are most crucial to assist the Hon'ble Commission in arriving at the truth and to decide whether or not there has been medical negligence in the present case (I) the Case Sheet of the deceased patient; (2) the Bed Head Ticket of the deceased patient and (3) the Treatment Chart of the deceased patient. A. As per our standard medical practice in South India, there is no such term as "bed head ticket". The records what we have maintained and filed before this Commission on 3.2.2004 would establish that there is no medical negligence nor any malpractice. The records relied upon by us are crucial: The patient in the Post Transplant room is looked after by a Nurse and duty doctor round the clock. The Nephrologists and Transplant Surgeon are with the patient during the first 12 hours and later visit the patient at least twice daily. In case of any problem, they stay with 'the patient and take care of him. They are in touch with the Nurse telephonically every" hour. While visiting the patient twice every day, the doctors enquire in the patient has any discomfort or any other symptom and examine him. In case of any problem, they stay with 'the patient and take care of him. They are in touch with the Nurse telephonically every" hour. While visiting the patient twice every day, the doctors enquire in the patient has any discomfort or any other symptom and examine him. If there is any such symptom, it is noted in the case sheet and appropriate investigations and treatment carried out promptly. In addition, the nurses maintain records for pulse, temperature, blood pressure, respiratory rate, fluid intake, fluid out-• put and drugs given chart every hour. My statement regarding the absence of any other infection is based on these records which have already been submitted to the Hon'ble Commission. In this case, Mr. Naveen Kant had no fever or any other symptom. The following cultures were Negative. Blood Culture - 14.11.1995 Urine Culture-13. 11 , 14.11; 15.11, 16.11, 18.11,20.11, 21.11,22.11.95 Drain Culture -17.11.95 USG of abodomen- No abnormalities on 14.11, 17.11, 21.11.95. On the basis of these records, we conclude that the patient had no infection at discharge, and the patient was doing well at the time of discharge. Q. 6 It is normal medical practice to discharge any patient, especially one who has undergone an organ transplant surgery, directly from the Intensive Care Unit (ICU) out of the hospital? A. After kidney transplantation, the patient is kept under "barrier nursing" in order to prevent any transmission of infection. This room has facilities for Cardiac and Oxygen monitoring. As the patient improves, the monitors are gradually withdrawn and the patient is made to sit up and walk. By the time of discharge, the patient walks about, feeds himself and uses the toilet on his own. This post-renal transplant room is not to be confused with Coronary Care Unit or Intensive Care Unit. Mr. Naveen Kant was discharged from the post-renal transplant room of which he was the sole occupant. Q.8 How did you ascertain whether or not there was any subjective evidence or symptom of infection in your patient, the deceased Naveen Kant? Do "the records" that you have referred to in• the third sentence of Paragraph 13 of your affidavit show that you had asked your patient to state if he had any feeling of pain or other discomfort at the site of the needle insertion in his left fore-arm? Do "the records" that you have referred to in• the third sentence of Paragraph 13 of your affidavit show that you had asked your patient to state if he had any feeling of pain or other discomfort at the site of the needle insertion in his left fore-arm? A. The first question we always ask while visiting patients is whether they have any discomfort, pain, cough, constipation, fever, loss of sleep or any other symptom. If any, such symptom is present, it is note a in the medical records and appropriate action taken. In the numerous notes in the caserecord of Mr. Naveen Kant there is not a single reference to any' pain in the forearm. Q. 10 According to you, what time does it take for the blood changes, such as a rise in the total leucocyte could due to cortico-steroid therapy, to return to normal? A. The transplant patient receives the highest dose of corticosteroids at the beginning and the dose is gradually reduced. In my experience, WBC count is elevated in about 2/3rd of post-transplant patients even without infection. It remains elevated for 2-4 weeks post-operation. Q.11 According to both you (vide paragraph 12 of your Affidavit deposition) and Dr. Sadayavel Kailasam {vide paragraph 16 of his affjdavlli the urinary catheter tip grew Klebsiella on 17.11.1995 for which J1e patient was started on Ciprofloxacin 3 days later, on 20.11.1995. What is your explanation for the delay in treatment of this infection of the patient? A. The urinary catheter tip was sent for culture on 17.11.1995. It was reported on 20.11.1995. Ciprofloxacin, the appropriate antibiotic, was started on 20.11.1995. So there was no delay. Q.12 Between 17.11.1995 and 20.11.1995, what antibiotics, if any, did you or Dr. P.S. Venkateswaran prescribe for the patient and which documents on record evidences such prescription? A. No antibiotics were prescribed between 17.11.1995 and 20.11.1995 as there was no evidence of infection. Q. 13 In paragraph 12 of your affidavit of deposition you state: "A course of Ciprofloxacin Was started on 20.11.1995 and was continued for five days". Yet in paragraph 13 you say that there was no evidence of any infection. How do you reconcile these two statements? A. In para 13 of my statement, I say that there was no evidence. subjective or objective, of any other infection. Besides, the bacterial growth of Catheter tip represents "Colonisation" and not "Infection". Yet in paragraph 13 you say that there was no evidence of any infection. How do you reconcile these two statements? A. In para 13 of my statement, I say that there was no evidence. subjective or objective, of any other infection. Besides, the bacterial growth of Catheter tip represents "Colonisation" and not "Infection". Actually urine cultures done on 18.11, 20.11, 21.11 and 22.11.1995 revealed no growth, thereby ruling out any urinary tract infection. Colonisation is different from infection and colonization need not necessarily be an infection. Q. 14 Even according to you: ','A rise in total leucocyte count is common in the, immediate post-transplant period and does not necessarily imply any infection" (vide paragraph 13 of you affidavit! deposition). What investigations, if any, did you conduct to rule out all possibility of any infection before you discharged the patient directly from the ICU on 24.11.1995? A. The following cultures were negative- 1. Blood culture 14.11.1995. 2. Urine culture on 13.11, 14.11, 15.11, 16.11, 18.11, 20.11, 21.11 and 22.11.1995. 3. Drain culture 17.11.1995. There was no fever or any other symptom. USG abdomen done onI4.11, 17.11 and 21.11.1995 was also within normal limits. Hence, there was no evidence of infection at the time of discharge. Q. 15 Please refer to your clinical notes (atpp. 169-173 of the complaint, Vol I) when you attended to the late Naveen Kant as your out patient between 24.11.1995 to 18.12.1995. Do these clinical notes record only your observations or do they also record the complaints made by the patient? A. The procedure followed in recently transplanted patients at my OP clinic is as follows: At discharge, the patient is asked record (a) High temperature at least 4 times daily using his own thermometer. (b) Fluid intake and output chart. (c) Daily weight. I always scrutinize the temperature chart and fluid chart and ask the patient if he has any symptom. I also ask about appetite, sleep and bowel movements. Then the patients weight is taken and a thorough examination carried out. The complaints and observations are then recorded in the patients file. (b) Fluid intake and output chart. (c) Daily weight. I always scrutinize the temperature chart and fluid chart and ask the patient if he has any symptom. I also ask about appetite, sleep and bowel movements. Then the patients weight is taken and a thorough examination carried out. The complaints and observations are then recorded in the patients file. Q. 16 I put it to you that on every visit as out patient upto 30.11.1995, viz., on 24.11.95, 25.11.1995, 27.11.1995,28.11.1995 and 30.11.95, the late Naveen Kant specifically complained to you about persisting pain in the left fore-arm- where the intravenous needle had been inserted in the ICU but you neither recorded his complaints nor took them seriously? A. No, it is incorrect to state that Mr. Naveen Kant specifically complained to me about the persisting pain in the left forearm where the LV. needle had been inserted in the ICU. It is further incorrect to state that, that I neither recorded Mr. Naveen Kant's complaint nor took it seriously. I am specifically denying your suggestions. Q. 17 According to you, after the onset of any infection, how long does it take for cellulitis/abscess to manifest themselves? A. It depends on the organisms concerned and the resistance of the patient. Once an organism gains entry, any time between a few hours to 48 hours later, cellulitis becomes clinically manifest, in an immuno suppressed patient. " Q. 18 I put it to you that, by definition, cellulitis/abscess are manifestations of infections one of whose classic and invariable symptoms is pain. Do you agree? A. As per clinical science, pain is a classic symptom of any inflammatory process. But the mere presence of pain would not necessarily mean infection. Q. 20 On what basis have you stated in paragraph 16 of your affidavit deposition that the complainant's allegations that the patient had pain and swelling in the left forearm are false, when in the same breathe you state that on 30.11.1995 you noted that the patient had developed fever and also cellulitis/ abscess in the patient's left forearm and have so recorded in your clinical notes of that date (at page 170 of the .complaint)? A. In para 16 of my statement, I state that the patient did not complain of left forearm pain as alleged in the annexure of the complaint (P. 61 and 62), till 30.11.1995. A. In para 16 of my statement, I state that the patient did not complain of left forearm pain as alleged in the annexure of the complaint (P. 61 and 62), till 30.11.1995. Only on 30.11.1995, the patient developed fever and left forearm cellulitis was diagnosed There is no record of any pain i:1 the left forearm as alleged prior to 30.11.1995. 1688 Q.21 You have deposed (vide paragraph 18 of your affidavit) that even after the abscess burst on 2.12.1995, the patient became febrile again on 5.12.1995 and then the abscess had to be incised and drained again by Dr. P.S. Venkateswaran, opposite party No.5, can you state the reasons for not advising re hospitalization of the patient even in the face of these persistent features? A. As per my notes (p. 172 complainants statement) after the I & Don 6.12.1]95, the in duration in the left forearm was settling down (as noted in the records 7.12.1995, 12.12.1995) and the temperature on 12.12.1995 was only occasionally 99°F. As the patient was improving, hospitalization was not thought necessary. On 12.12.1995 (in vide pages 172/176 of the complaint) despite noting that the patient had persisting fever and in duration, you issued a final prescription and relieved yourself of the obligation of keeping the patient under your continuing supervision. Are these facts not true? A. Not true. I never absolved myself of the responsibility at any time. Actually, according to the records I have seen the patient again on 16.12 and 18.12.1995 and given further prescription. As per standard medical practice, there is nothing called as final prescription. Further, the prescription dated 12.12.1995 does not say anywhere that it is a final prescription. It would be relevant to mention here that on the same prescription sheet dated 12.12.1995, the prescriptions made on 16.12.1995 have also been recorded. Q. 23 According to your prescription dated 12.12.1995, you left the patient without any cover of antibiotics after the morning of 15.12.1995. Is that correct? A. It is incorrect to state that the patient was left without any cover of antibiotic from the morning of 15.12.1995. It is crucial to note that Quintor (Ciprofloxacin) which is an effective antibiotic was prescribed for 3 days 13.12, 14.12, 15.12.1995. Further on 16.12.1995, the patient was prescribed Vancomycin. Q. 27 At what time you were a "Specialist Consultant" to the K.S. Hospital, opposite party No.4. Is that correct? It is crucial to note that Quintor (Ciprofloxacin) which is an effective antibiotic was prescribed for 3 days 13.12, 14.12, 15.12.1995. Further on 16.12.1995, the patient was prescribed Vancomycin. Q. 27 At what time you were a "Specialist Consultant" to the K.S. Hospital, opposite party No.4. Is that correct? A. I was visiting K.S. Hospital as a Consultant Nephrologist. Q.28 You have deposed: "I state that the patient was advised to get admitted in the hospital. The patient himself chose the 4th opposite party" (vide paragraph 19 of your affidavit). Did you specifically advise the patient to get readmitted to the ASNH, opposite party No.6? A. Both ASNH and KS Hospital are good hospitals with facilities for taking care of the patient after transplantation. Actually, Mr. Naveen Kant himself used to have regular haemodialysis at K. S. Hospital for three months prior to transplantation. It is possible that he chose K.S. Hospital be cause he was familiar with the hospital and he knew that it was less expensive. The patient himself chose the 4th opposite party. Therefore, the question of me suggesting any other hospital including the 6th opposite party did not arise at that time. Q.29 You were aware that the K.S. Hospital, opposite party No.4 was not a hospital registered under the Transplantation of Human Organs Act, 1994 read with the 95 Rules made there under. Is that true? A. True. I further state that the patient was not admitted to opposite party No. 4 (KS. Hospital) for conducting transplantation surgery. The patient was admitted in KS. Hospital for management of malaria and cellulitis. Q.32 Regarding the patient's second re-hospitalisation, the very same discharge summary dated 31.1.1996 of the KS. Hospital concludes with the sentence: "Patient transfer to St. Isabel's Hospital on the advice of Dr. M.A. Muthusethupathy (vide pages 77/ 216 of the complaint, Vol.1). Are you suggesting that your patient acted against your advice in getting admitted to the KS. Hospital, opposite party No.4 but on your advice in being transferred to the St. Isabel's Hospital, opposite party No.7? A. I do not suggest that the patient acted against my advise in getting admitted to KS. Hospital. The patient was in KS. Hospital from 21.12.1995 to 31.1.1996 under my care. Since it was felt that the patient. required prolonged mechanical ventilation, which was available only in a few hospitals. Isabel's Hospital, opposite party No.7? A. I do not suggest that the patient acted against my advise in getting admitted to KS. Hospital. The patient was in KS. Hospital from 21.12.1995 to 31.1.1996 under my care. Since it was felt that the patient. required prolonged mechanical ventilation, which was available only in a few hospitals. I advised the patient to be transferred to St. Isabel's Hospital. There is no contradiction with respect to the admission of the patient at KS. Hospital and my advice regarding re-hospitalization in the St. Isabel's Hospital on 31.1.1996. Q.38 How had you deposed to the factual matter mentioned in paragraphs 20 and 21 of your affidavit when, admittedly, you were out of town from 23.12.1995 to 31.12.1995? A. Even though I was out of town, attending to my sick wife, I was in touch with Dr. Shivkumar and Dr. KK Bhatt over phone regularly. I also perused the records of the hospital after I came back. I had personal and direct interaction with the doctors who attended the patient. I also got the required information from the patient himself. Q. 39 In paragraph 20 of your affidavit, you have deposed: "As per the hospital records and observations there is no purulent discharge and pus". I put it to you that there is no such statement in the records of the KS. Hospital, opposite party No.4 which were served upon the complainants and filed before this Hon'ble Commission only on 29.12.2003? A. I again reiterate that on perusal of the records of KS. Hospital, there is a specific note by Dr. P.S. Venkateswaran on 26.12.1995. It says "Wound healthy, no purulent discharge, dressing done". I deny your suggestion that there is no such statement in the records of the KS. Hospital. Q.49 You further say in the same paragraph that the patient wanted to get admitted in the KS. Hospital to minimize his expenses. : put it to you that your statement is untrue? A. It is incorrect to state that my statement is untrue. 12. Answers given in the cross-examination of the relevant questionnaires put to Dr. P.S. Venkateswaran, opposite party No.5 are reproduced below: Q. 2 Is it correct to say that late Naveen Kant (the patient) presented himself before you at the Aswini Soundra Nursing Home (ASNH) on 29.11.1995,1.12.1995 and 6.12.1995, after his discharge from ASNH? A. Yes. 12. Answers given in the cross-examination of the relevant questionnaires put to Dr. P.S. Venkateswaran, opposite party No.5 are reproduced below: Q. 2 Is it correct to say that late Naveen Kant (the patient) presented himself before you at the Aswini Soundra Nursing Home (ASNH) on 29.11.1995,1.12.1995 and 6.12.1995, after his discharge from ASNH? A. Yes. Q.3(a) Do you think the said cellulitis/ abscess could have manifested themselves on 30.11.1995, all of a sudden, without there being any infection from before? A. Yes. A cellulitis/abscess would have manifested itself all of a sudden. Q.3(b) If not, by how many days would the onset of the infection have preceded the manifestation of the said cellulitis/ abscess, according to you? A. In a patient who is immuno suppressed, the interval between the onset of infection and development of cellulitis /abscess will usually be a few hours to 48 hours, depending on the organism and resistance of patient. Q. 5 Is it correct to say that on 6.12.1995 you had incised the abscess on the left forearm of the patient? A. Yes. Q. 6 Were you aware to say that's on 6.12.1995 that the abscess had burst at 4 p.m. on 2.12.1995 as noted by Dr. Muthusethupathi (see page 171 of the complaint)? A. Yes. Q.7(a) is it correct to say that you were the principal surgeon of the team who actually performed the transplant operation? As the chief surgeon, and consultant to. ASNH, did you consider it part of your responsibility to address the infection that manifested itself in the immuno suppressed patient as a very serious matter needing urgent and concerted action for its total eradication? A. es. There was no complaint of any pain by the patient until discharge on 24,11.1995 and also even on 29.11.1995, when the patient visited me for abdominal wound dressing (Transplant Wound). The abdominal wound was healthy. Even on this date, the patient never complained about any pain in the forearm. 7(b) If yes, what steps did you individually take in that direction? Please specify. A. Since there was no infection nor any pain complained of by the patient, there was no necessity for me to take any steps. The abdominal wound was healthy. Even on this date, the patient never complained about any pain in the forearm. 7(b) If yes, what steps did you individually take in that direction? Please specify. A. Since there was no infection nor any pain complained of by the patient, there was no necessity for me to take any steps. Q. 8 Specifically, according to you, was it or was it not necessary and in the interests of the patient to hospitalize him immediately for thorough exploration of the infection and complete draining of the pus to eliminate any chance of the infection spreading? If it was necessary, when did you advise the patient's re-hospitalization and where did 'you record it? A. incision and complete drainage (I and D) of the forearm abscess was done as out patient on 6.12.1995. The abscess was a shallow one and did not require any exploration. Since the patient was on appropriate antibiotic cover, no hospitalization was necessary. Q. 11 Are you a Consultant to K.S.Hospital, opposite party No.4? A. No. I am not a consultant to K.S. Hospital, opposite party No.4. But being a member of the kidney transplant team, I visited the patient whenever I was called to attend the patient. Q. 13 The KS. Hospital's case sheet, as filed on record, shows that after patient was admitted there on 21.12.1995, on 23.12.1995 you made an incision to drain out all pockets of pus in the patient's left forearm since this was are• currence after you had earlier drained out the pus on 6.12.1995, what responsibility towards the patient did you assume between 6.12.1995 and 23.12.1995 and how did you discharge that responsibility? Please specify. In particular, how many times and on what dates did you attend to the patient? A. After the Incision and Drainage on 6.12.1995, I advised the patient to come and see me again. But the patient did not turn up. It appears from the records produced by the complainant that one Dr. Yathinder Kumar was attending the patient and doing the dressing. On 23.12.1995, I was called to K.S. Hospital. After examination of the patient, I performed I and D. Despite my advice the patient did not meet me between 6.12.1995 and 23.12.1995. Q.l4(a) Did you give any specific instructions for proper dressing of the wound in the patient's left forearms to the staff of the K. S. Hospital? On 23.12.1995, I was called to K.S. Hospital. After examination of the patient, I performed I and D. Despite my advice the patient did not meet me between 6.12.1995 and 23.12.1995. Q.l4(a) Did you give any specific instructions for proper dressing of the wound in the patient's left forearms to the staff of the K. S. Hospital? And, if so. where are those instructions recorded? A. I had given oral instructions, for proper dressing of the wound in the patient's left forearm to Dr. KK Bhatt and his staff. As per standard medical practice, the instructions regarding dressing of an wound will not be in writing. Q. 16 in paragraph 20 of the counter affidavit filed by 'opposite parties Nos. 1,2, and 5 affirmed by Dr. M. A. Muthusethupathi (which is the same as paragraph 20 of his evidences by way of affidavit also dated 21. 7 .2002) which you have adopted, it is stated: "As per the hospital records and observations there is no purulent discharge and pus". I put it to you that there is no such statement in the records of the KS. Hospital, opposite party No.4 which was served upon the complainants and filed before this Hon'ble Commission only on 29.12.2003? A. I had made an observation and recorded in the case sheet of KS. Hospital on 26.12.1995 "Wound healthy, no purulent discharge. dressing done". I deny your suggestion that there is no such statement in the records of the KS. Hospital. 13. In his affidavit, said Dr. S. Sunder, Director and Chief Nephrologist of Karnataka Nephrology and Transplant Institute, Bangalore stated that out of his own experience in having performed 1250 kidney transplantation surgery in the past 22 years and based on the evidence of literature relating to kidney transplantation, increase in total count (leucocytes) is a common phenomena in most of the renal transplant recipients who has been administered corticosteroids. The rise in total count does not per se mean infection so there is no reason to conclude that the patient ought not to have been sent home on 12 day of surgery. Statement by a witness that leucocyte count will not rise in the post-transplant period in absence of any infection only proves lack of experience and medical knowledge of renal transplant. He further stated that on 30.11.1995 after diagnosing cellulitis/abscess injection Reflin was started by opposite party No. 1. Statement by a witness that leucocyte count will not rise in the post-transplant period in absence of any infection only proves lack of experience and medical knowledge of renal transplant. He further stated that on 30.11.1995 after diagnosing cellulitis/abscess injection Reflin was started by opposite party No. 1. Reflin is the best medicine for cellulitis and it is a common practice to use this drug in such a situation. He denied that Reflin is not the right choice of medication for cellulitis. He further state that medical science is not an exact science like mathematics and in medical science experience of the doctor treating the patient is important. In this case there was no evidence of surgical wound infection as per the medical record. He also averred that most transplant patients having fever are treated with drugs like Amikacin and Ciprofloxacin to cover a broader spectrum of organisms in absence of definitive evidence of organism causing fever. Amikacin is not to be used in the usual dose of 15 mg. per kilogram. It is always used in a lower dose as transplant kidney is vulnerable for damage by this drug. The dosage, continuation of the dosage and discontinuation are purely based of the experience of the treating doctor. Normally, in renal transplant cases, drug Amikacin is not continued for more than 7 to 10 days in view of toxicity to the kidney. In this case, this drug was lightly stopped after a particular dosage to avoid any damage to the kidney. He stated that in his experience in the field of Kidney Transplantation and Nephrology, it is very difficult to diagnose and manage any infection in a Kidney Transplant patient. The reasons are: (a) Cultures of body fluids (blood, urine, pus, etc.) are often negative. (b) Even if an organism is isolated, it is not always possible to be certain that the particular organism is the actual cause of fever. (c) Many of the antibiotics have deleterious effects on the transplanted kidney, thereby necessitating great care in drug selection and dosage. (d) Un-related donor transplantations need more immuno-suppression . for the kidney to survive and therefore are more prone to infection. 14. Blood culture, urine culture, oral swab culture and cultures of discharge from the forearm were repeatedly negative and did not yield any organism: In such cases, antibiotics like Amikacin & Ciprofloxacin are usually administered empirically. (d) Un-related donor transplantations need more immuno-suppression . for the kidney to survive and therefore are more prone to infection. 14. Blood culture, urine culture, oral swab culture and cultures of discharge from the forearm were repeatedly negative and did not yield any organism: In such cases, antibiotics like Amikacin & Ciprofloxacin are usually administered empirically. A person who had undergone a renal transplant and on immuno suppressive therapy may not respond to antibiotic therapy.' in fact, renal transplantation is not without any risk. The textbook of Nephrology, by Sir Douglas Black; in the chapter on kidney transplant says that, "Renal Transplant is like a marriage. A boon for many, it is a curse for some and a risk for all." 15. In reply to the following questionnaire the answers given by this witness were as under : Q.15 In paragraph 29 of your affidavit of evidence you have deposed: "I am of the strong opinion that 'Reflin' is the best medicine for cellulitis and it is the common practice to use .this drug in such a situation". Please explain then how it was that "the best medicine", according to you, for treatment of cellulitis failed to arrest the infection and deterioration in the condition of the patient, as is evidenced by (a) the reappearance of the abscess at the very site on the patient's left forearm even after it had burst on 2.12.1995 and (b) the fact that the abscess/pus had to be drained out by incision and drainage on 6.12.1995 and again on 23.12.1995 and yet again on 2.1.1996 by Dr. P.S. Venkateswaran, opposite party No.5? A. I respectfully submit that, the term "Best Medicines" really means the medicines found effective and safe in the vast majority of such infections in the experience of the doctor. It certainly does not mean that the drug will be effective and safe in every such infection. In this case, Inj. Reflin was given for 5 days (30.11.1995-4.12.1995), Inj. Amikacin and Ciprofloxacin were given from 5.12.1995 to 12.12.1995. Due to the reason that this patient had not fully responded for the best medicine like Reflin, one cannot conclude that Reflin as ineffective medicine where it has been administered successfully to the large number of Renal Transplant patients. In this case, Inj. Reflin was given for 5 days (30.11.1995-4.12.1995), Inj. Amikacin and Ciprofloxacin were given from 5.12.1995 to 12.12.1995. Due to the reason that this patient had not fully responded for the best medicine like Reflin, one cannot conclude that Reflin as ineffective medicine where it has been administered successfully to the large number of Renal Transplant patients. Q.22 In paragraph 29 at page 30 of your affidavit, you have stated: "In certain cases, an antibiotic is started on an empirical basis even without obvious investigative support". In this context please refer to para 12.8 of Dr. Sophia Ahmed's affidavit of evidence where she has cited Harrison's Principles of Internal Medicine, which states that empirical treatment pending investigative support through antimicrobial susceptibility data warrants an administration to the patient of a third generation Cephalosporin. Is Injection Reflin ~ third generation Cephalosporin? If not, why do you justify and support its being administered and persisted in for 4 days for the patient in the present case? . A. I respectfully submit that, when an infection warrants the use of an 'antibiotic and no organism has yet been identified, the procedure is to start the antibiotic most likely to be effective against the most probable bacteria causing the infection. For example, for Urinary Tract Infection, where the most likely cause is Esch. Coli, an antibiotic likely to be most effective (Eg. Ciprofloxacin) against Esch. Coli according to locally available sensitivity data will be started. For cellulitis, the most likely cause is Staph or Strep and an antibiotic like Inj. Reflin will be the logical choice. Q. 59 With reference to para 48 of your affidavit under the caption ~'Effect of Immuno Suppressive Therapy", please answer the following questions: (i) Is not tissue compatibility the only factor governing the survival of the transplanted kidney, whether the recipient is related to the donor or not? (ii) Is it not a fact and an ad matted position of the parties in the present case that the kidney transplant operation was entirely successful? (iii) Whose case is that the transplanted kidney was rejected by the recipient-patient's system in the present case? (iv) Which medical record and whose deposition (inc using yours) in the present case states that the transplanted kidney was rejected by the recipient-patient's body? A. (i) "Tissue compatibility" is only one of several factors governing the survival of transplanted kid0ey. (iii) Whose case is that the transplanted kidney was rejected by the recipient-patient's system in the present case? (iv) Which medical record and whose deposition (inc using yours) in the present case states that the transplanted kidney was rejected by the recipient-patient's body? A. (i) "Tissue compatibility" is only one of several factors governing the survival of transplanted kid0ey. - (ii) Yes. (iii) Nobody's case-but patient who received kidney from un-related donor is unlikely to have HLA. identify and 'chances of rejection are mere. Only in this context mere immunosuppressive becomes necessary which pre-disposes to mere infection. (iv) No. 16. Dr. Arun Kumar, Professor of Surgery, Head of the Department of Surgery, Combater Medical College, Tamilnadu in his affidavit stated that he has been a kidney transplant surgeon since 1986 and was part of the team that has performed over 1140 renal transplantations. He found no evidence of any forearm pain or infection in the records. In clinical practice, positive findings, if any, are always noted in the case records. Foley's catheter growth by itself usually represents "Colonization" and not "Infection" whereas a rise in total was count can be seen in the post-transplant period without any infection. This has been well documented and is due to high dose corticosteroid therapy (DANOVITCH ~A Handbook of Kidney Transplantation). In the absence of any Clinical finding of infection as well as the fact that all cultures were negative make it certain that there was no infection at the time of discharge and it was by way of abundant caution, the patient had been put on Ciprofloxacin from 20.11.1995 to 27.11.1995 for the Klebsiella colonization of the Foley catheter tip. Despite broad spectrum antibiotic and anti-TB therapy, the patient unfortunately succumbed to his illness. He did not find any evidence of infection at the time of discharge from Aswini Soundra Nursing Home. 17. Answers in cross-examination to the following relevant questionnaires were as under: Q. 2 Approximately how many cases of infection, like the one suffered by late Naveen Kant have you handled? A. I respectfully submit that. I have handled infections of different types occurring in the post-transplant patients,. approximately 3• 4 cases in a year. Q. 3 What was the success rate in such cases of infection after renal transplant? A. I respectfully submit that, some infections subside with treatment, some infections continue to progress in spite of treatment. A. I respectfully submit that. I have handled infections of different types occurring in the post-transplant patients,. approximately 3• 4 cases in a year. Q. 3 What was the success rate in such cases of infection after renal transplant? A. I respectfully submit that, some infections subside with treatment, some infections continue to progress in spite of treatment. The response depends on the state of immunity of the concerned individual. Q. 5 In para 3 of your affidavit you have said that it is an established fact that when kidney transplantation is carried on between individuals who are not genetically related, the chances of opportunistic infections are higher. Is there any authority to support this theory? . . A. I respectfully submit that, the less genetically-related the donor-recipient pair the more the chances of rejection and hence the more aggressive the immuno suppression needed to prevent rejection. More immuno-suppression means more infection episodes. Any book on organ transplantation will vouch for this. Q. 7 Approximately what was the percentage of the catastrophic situations referred to by you in para 3 of your affidavit, in which it became impossible to control the infection with the best available treatment? A. I respectfully submit that, in para No.3 of my affidavit! have stated that such opportunistic infections may, at times be impossible to control with best available treatment for which exact percentage cannot be given. Q. 11 Are you satisfied that negative results of cultures of blood, urine and drain on basis of single samples, were reliable evidence of non-existence of infection? Was it not necessary to take repeated samples at frequent intervals to find out the cause of infection as suggested by Dr. (Col.) Ashok Chopra in para 18 of his affidavit? A. I respectfully submit that, in my well considered opinion, enough cultures, as and when required, have been done in the instant case. Particularly, in this case there was no growth of any organism despite repeated cultures. Q. 20 According to you, before an infection gets aggravated into or manifests itself as indurations, cellulitis and abscess accompanied by fever, would there or would there not be preceding symptoms such as pain, swelling or fever? If your answer is in the negative, please support it with citation of medical authority? Q. 20 According to you, before an infection gets aggravated into or manifests itself as indurations, cellulitis and abscess accompanied by fever, would there or would there not be preceding symptoms such as pain, swelling or fever? If your answer is in the negative, please support it with citation of medical authority? A. I respectfully submit that, the cellulitis may occur suddenly without any preceding pain especially in a immuno compromised patients in my experience in this field. 18. Complainants do not dispute that kidney transplant operation of Naveen Kant was done successfully on 12.11.1995. Medical negligence/deficiency in service alleged by the complainants pertains to post-operative period. Thrust of the submissions advanced on behalf of the complainants was that- (i) onset of fever and chill on 14.11.1995; (ii) urinary Catheter tip going Klebsiella as reported on 20.11.1995; (iii) total leucocyte counts being 25,900 as against the normal range of 3000 to 11000 as per the test report dated 23.11.1995 and percentage of Polymorphs being 87 as against the normal range of 55% to 65% as per the test report dated 24.11.1995, (iv) appearance of cellulitis in left forearm on 30.11.1995 which had the onset prior to Naveen Kant's discharge from opposite party No.6 on 24.11.1995; and (v) pain in left forearm at the site where needle was inserted for injection of drugs and fluids which persisted •even after discharge from opposite party, dearly indicated that infection was still there in the body of Naveen Kant and opposite party Nos. 1, 5 and 6 were grossly negligent in discharging him on 24.11.1995. Opposite parties were also negligent/deficient in service in not timely prescribing potent antibiotic drugs upto 3.1.1996 when Naveen Kant was shifted to opposite party No.7hospital and repeating his investigations at frequent intervals of the blood, urine and sputum to find out the causative micro-organism responsible for the infection. 19. Needless to repeat that in the written version filed by opposite party No.1 which was adopted by opposite party No.5, it is pleaded that on 13 .11.1995, Naveen Kant developed low grade fever for a few hours in the morning. There was no evidence of any bacterial infection. He was given injection Reflin and his temperature normalized in the after noon. On 14.11.1995, he had fever and chills. So, blood was sent for testing to the lab and injection Fortum was started. There was no evidence of any bacterial infection. He was given injection Reflin and his temperature normalized in the after noon. On 14.11.1995, he had fever and chills. So, blood was sent for testing to the lab and injection Fortum was started. Blood test for malaria parasite was positive and he was started on Nivaquine. Blood culture for bacteria was negative. Patient attained normal temperature from 15.11.1995 and the temperature remained so till discharge. It is further pleaded that urine catheter tip grew Klebsiella on 17.11.1995 though the urine culture was sterile. A course of Ciprofloxacin was started from 20.11.1995 which was continued for five days. Had there been any complaint by Naveen Kant of the pain in fore-arm it would certainly have been looked into very carefully. Immuno suppressive drugs are essential to prevent rejection of transplanted organ. Rise in total leucocyte count is common in immediate post-transplant period and it does not necessarily imply any infection. Rise is related to high dose steroid therapy. Condition of Naveen Kant was quiet satisfactory and normal until 30.11.1995 when it was noted that he had fever on that date and developed cellulitis in left forearm for the first time. Injection Reflin which is one of the best antibiotic for cellulites was started. On 2.12.1995, it is mentioned in records that abscess burst around 4.00 p.m. On 4.12.1995 it was found that temperature was settling but on 5.12.1995 the patient was febrile. Injection Amikacin was added. On 6.12.1995, abscess was incised and drained by opposite party No.5. Patient visited on 12.12.1995 and Quintor was added in view of the• persistence of fever. In reply to interrogatory No.3 opposite party No. 1 stated that patient had visited twice everyday and the doctors enquired from him if he had any discomfort or any other symptom and if there is any such symptom it is noted in the case sheet and appropriate investigations and treatment are carried out promptly. Nurses maintain records for temperature, etc. Naveen Kant had no fever or any other . symptom, blood culture on 14.11.1995, urine cultures on 13.11.1995, 14.11.1995, 15.11.1995, 16.11.1995, 18.11.1995,20.11.1995,21.11.1995 and 22.11.1995 and drain culture on 17.11.1995 were negative. No abnormality was detected in the USG of abdomen on 14.11.1995, 17.11.1995 and 21.11.1995. On the basis of these reports it was concluded that Naveen Kant had no infection at the time he was discharged. symptom, blood culture on 14.11.1995, urine cultures on 13.11.1995, 14.11.1995, 15.11.1995, 16.11.1995, 18.11.1995,20.11.1995,21.11.1995 and 22.11.1995 and drain culture on 17.11.1995 were negative. No abnormality was detected in the USG of abdomen on 14.11.1995, 17.11.1995 and 21.11.1995. On the basis of these reports it was concluded that Naveen Kant had no infection at the time he was discharged. In reply to interrogatory No. 10, opposite party No. 1 stated that transplant patients receive highest dose of Corticosteroid in the beginning which is gradually reduced and in his experience, WBC count is elevated in above 2/3 of transplant patients, even without infection. It remains elevated for 2 to 4 weeks postoperative. In reply to interrogatory No. 11, he replied that urinary catheter tip grew Klebsiella and Ciprofloxacin was started on 20.11.1995 which was continued for five day.:. In reply to interrogatory No. 13, opposite party No. 1 stated that bacterial growth of the catheter tip represents 'colonisation' and nonfiction and 'colonisation' is different from infection and 'colonisation' need not necessarily be an infection. In reply to interrogatory No. 16, opposite party No. 1 emphatically denied that Naveen Kant had specifically complained to him of persistent pain in the left forearm where LV. needle was inserted in ICU but he did not record this complaint nor did he seriously take it. In response to interrogatory No. 17 he stated that fEW hours to 48 hours are taken in cellulitis becoming clinically manifested in an immuno suppressed patient. In answer to interrogatory No. 21 he further stated that after J.D. on 6.12.1996, left forearm was settling. Opposite party No.5 in reply to interrogatory No. 3(a) that did he think that cellulitis/abscess could have manifested on 30.11.1995 all of a sudden. Opposite party No.5 stated that cellulitis/ abscess it have manifested itself all of a sudden. In answer to interrogatory No. 3 (b) he stated that development of cellulitis/abscess usually takes a few hours. to 48 hours depending on the organism and resistance of patient. In reply to interrogatory No.7, opposite party No.5 stated that there was no complaint of any pain by Naveen Kant until discharge on 24.11.1995 and also even on 29.11.1995 when he visited him for abdominal wound dressing (transplant wound). In answer to interrogatory No.8 he replied that incision and complete drainage of the forearm abscess was done by him on 6.12.1995. In answer to interrogatory No.8 he replied that incision and complete drainage of the forearm abscess was done by him on 6.12.1995. Abscess was shallow one and did not require any exploration and hospitalisation. In answer to interrogatory No. 13, he replied that after incision and drainage on 6.12.1995, he advised Naveen Kant to come and see him again but he did not turn up. On 23.12.1995 he was called to opposite party No.4-hospital where he performed I and D. Dr. S. Sunder in answer to interrogatory No. 22 in regard to efficacy of injection Reflin replied that for cellulitis the most likely cause is staph or strap and antibiotic like injection Reflin will be the logical choice. Dr. K.P. Arun Kumar in answer to interrogatory No. 11 replied that enough cultures, as and when required, had been done in this case and no growth of any organism was detected despite repeated cultures. In reply to interrogatory No. 20 he replied that in his experience in the field, cellulitis may occur suddenly without any preceding pain particularly in an immuno suppressed patient. 20. At the cost of repetition it may be mentioned that the affidavits of Col. (Dr.) Ashok Chopra and Dr. (Mrs.) Sophia Ahmed have been filed as expert witnesses by the complainants. In answer to interrogatory No. 34 if you find any evidence of infection at the time of discharge of Naveen Kant from opposite party No. 6nursing home, Dr. Chopra stated that there is evidence of infection in the shape of high TL;C in the report dated 23.11.1995, high polymorphs in the report dated 24.11.1995 and appearance of cellulitis/abscess in the left forearm on 30.11.1995. In reply to interrogatory No. 41 that cellulitis was found only on 30.11.1995, Dr. Chopra replied that existence of cellulitis has been recorded for the first time on 30.11.1995 but it could not be said that it was detected for the first time on that date. Cellulitis is not an overnight development. In answer to interrogatory No. 134 that total leucocyte count may increase in post transplant-patients without any evidence of infection, he replied that blood cells come back to normal after 24 hours of the administration of corticosteroids. In reply to interrogatory No. 136 that fever and chill on 14.11.1995 were only due to malaria and the patient responded to anti-malarial treatment with no further rise in temperature, Dr. In reply to interrogatory No. 136 that fever and chill on 14.11.1995 were only due to malaria and the patient responded to anti-malarial treatment with no further rise in temperature, Dr. Chopra stated that after going through the records of opposite party No. 6-nursing home it was wrong to say that patient's febricity on 14.11.1995 was only due to malaria and patient responded to anti-malarial treatment. He claimed that fever was also due to hosocomial infection. In answer to interrogatory No. 139, he admitted that as per the reports of opposite party No.6 at the time of discharge on 24.11.1995 Niween Kant was not having any fever. 21. Dr. (Mrs.) Sophia Ahmed in answer to interrogatory No. 34 that as per the hospital records the condition of Naveen Kant was normal before discharge from hospital, she stated in negative. In answer to interrogatory No. 38 that can she find any evidence of infection 'at the time of discharge from opposite party No. 6-nursing home, she replied that there was ample evidence of infection. In answer to interrogatory No. 117 whether from hospital records was there any symptoms such as pain, swelling, in duration noted in the case sheet till the time of discharge, she stated that it does not appear from the hospital records of opposite party No. 6-nursing home now made available that any such symptom is noted in the case sheet till the patient was discharged. She stated that in paragraph 12.7 of her affidavit she has explained that the manifestation of cellulitis/ abscess in patient's left forearm relates back to patient's nosocomial infection. 22. Between 12.11.1995 and 14.11.1995 when Naveen Kant was in opposite party No.6-nursing home the opposite party Nos. 1,5 and 6 would not have even visualized that they will be dragged in litigation. There was hardly any occasion either for opposite party No.1 or opposite party No. 5 or for the other attending doctors and the nurses of opposite party No.6 not to have mentioned in the records the complaint of Naveen Kant of his having pain in the left forearm. Thus, there seems to be no reason not to believe opposite party No. 1 and/ or opposite party No.5 that Naveen Kant did not make any complaint regarding pain in the left forearm before he was discharged from opposite party No.6-nursing home. Thus, there seems to be no reason not to believe opposite party No. 1 and/ or opposite party No.5 that Naveen Kant did not make any complaint regarding pain in the left forearm before he was discharged from opposite party No.6-nursing home. Statement of Col.(Dr.) Ashok Chopra and Dr.(Mrs.) Sophia Ahmed of Naveen Kant's having pain in the left forearm being based on contactors cannot be believed. From the statement of opposite party No. 1 which is based on the records of opposite party No.6-nursing home and the memory, it is established that onset of . fever and chills on 14.11.1995 was because of malaria and the same was controlled by giving Negaunee, fever had settled on 15.11.1995 and there was no fever till the date of discharge on 24.11. ~ 995. As stated by opposite party No. 1 and corroborated. by Dr.. Arun Kumar, growing of Klebsiella on the tip of catheter was due to 'colonisation' and not 'infection' and 'colonisation' is different from 'infection' and 'colonisation' need not necessarily be 'infection'. Even for Klebsiella a course of Ciprafloxacin was started on 20.11.1995 and continued for five days. Much emphasis was laid on behalf of the complainants on two reports dated 23.11.1995 and 24.11.1995. In the test report dated 23.11.1995 to talleucocyte count was reported to be 25,900 as against the normal range of 3,000 to 11,000. In the report dated 24.11.1995, Polymorph was reported to be 87% as against normal range of 55% to 65%. It is in the statement of opposite party No.1 which is supported by the statements of Dr. S. Sunder and Dr. Arun Kumar that transplant patients receive highest dose of corticosteroids at the beginning which is gradually reduced and WBC counts remain elevated in about 2/3 of the post transplant patients even without infection. for 2 to 4 weeks post-operation. Expert• witnesses examined by the complainants, Col. (Dr.) Ashok Chopra and Dr. (Mrs.) Sophia Ahmed are nqt the nephrologists nor had they conducted any renal transplant surgery. Whereas the experts witnesses examined by opposite parties, Dr. S. Sunder and Dr. Arun Kumar had been the members of the teams having done hundreds of renal transplantations and their opinion about raised total leucocyte count, Polymorph in post-transplantpatients-even without any infection and total leucocyte count remaining elevated for 2 to 4 weeks post-operation has to be given preference over the statements of Col. S. Sunder and Dr. Arun Kumar had been the members of the teams having done hundreds of renal transplantations and their opinion about raised total leucocyte count, Polymorph in post-transplantpatients-even without any infection and total leucocyte count remaining elevated for 2 to 4 weeks post-operation has to be given preference over the statements of Col. (Dr:) Ashok Chopra and Dr. (Mrs.) Sophia Ahmed that elevated total counts come back to normal within 24 hours. Based on the two reports it is difficult to return a finding that Naveen Kant was having infection at the time of discharge on 24.11.1995. Yet another circumstance on which heavy reliance was placed on behalf of the complainants was that Naveen Kant was found having cellulitis in left forearm on 30.11.1995 by opposite party No.1. Aforesaid two expert witnesses examined by the complainants state that it had the onset prior to discharge. It is in the cross-examination of opposite party Nos. 1 and 5 that cellulitis can appear within few hours to 48 hours all of a sudden in immuno suppressed patient. Considering the vast experience of opposite party Nos. 1 and 5 in the field of nephrology we are inclined to believe them that cellulitis can appear suddenly within few hours to 48 hours depending on the organism and resistance of a patient. Reports of Blood culture on 14.11.1995, Urine culture on 13.11.1995, 14.11.1995, 15.11.1995, 16.11.1995, 18.11.1995,20.11.1995 and 22.11.1995, Drain culture on 17.11.1995 being negative and there being no abnormality on 14.11.1995, 17.11.1995 and 21.11.1995. The USG of abdomen were suggestive of no infection in the patient on 24.11.1995. From the aforesaid discussion, it must be followed that Naveen Kant did not have any infection in the body at the time of discharge from opposite party No. 6-nursing home on 24.11.1995. 23. While quoting that approval the Bolam's test, the Supreme Court in Jacob Mathew v. State of Punjab & Anr., III (2005) CPJ 9 (SC) =III (2005) CCR 9 (SC)=VI (2005) SLT 1 =122 (2005) DLT 83 (SC) =2005 (6) Scale, in para No. 19 of the judgment at page 140 of the report held: "a professional may be held liable for negligence on one of two findings: either he was not possessed of the requisite skill which he professed to have possessed, or, he did not exercise, with reasonable competence in the give case, the skill which he did possess. The standard to be applied for judging, whether the person charged has been negligent or not, would be that of an ordinary competent person exercising ordinary skill in that profession. It is not necessary for every professional to possess the highest level of expertise in that branch which he practices. " 24. Opposite party No. 1 possesses D.M. degree in Nephrology. He held senior positions in Government Hospitals in Tamil Nadu and has performed over 900 live donor kidney transplantations. He has trained more than 48 candidates for the degree of D.M. (Nephrology) and DNB (Nephrology). He, thus, possessed the requisite skill of performing kidney transplant operation of Naveen Kant and manage his post-operative care. Opposite party No.5 possesses MIC, Vascular Surgery qualification and has performed over 500 kidney transplantations and has extensive general and vascular surgery experience of nearly 30 years. Opposite party Nos. 2 and 3 had followed the instructions given by opposite party No.1 and 5. Two charts giving the details of antibiotics administered from time-to-time to Naveen Kant and the results of investigations which had been prepared on the basis of hospital records, are appended to the written submissions filed by opposite party Nos.1, 2,5 and 6. Col. (Dr.) Ashok Chopra and Dr. (Mrs.) Sophia Ahmed in their cross-examination have affirmed the giving of the antibiotics as given in the chart with minor variations. Chart would show that Naveen Kant was on antibiotics from 12.11.1995 to 14.11.1995,20.11.1995 to 27.11.1995, 30.11.1995 . to 4.12.1995,5.12.1995 to 12.12.1995, 12.12.1995 to 15.12.1995, on 16.12.1995, from 21.12.1995 to 28.12.1995, on 2.1.1996, from 3.1.1996 to 5.1.1996, from 9.1.1996. to 14.1.1996, from 3.1.1996 to 13.1.1996, from 16.1.1996 to 23.1.1996 and 31.1.1996 to 3.2.1996. As regards efficacy of the antibiotic drugs given, opposite party-doctors were the best judges to decide what antibiotic drugs were to be prescribed and for which duration that may not injure the transplanted organ. Chart of investigations would indicate that blood culture (2) on 14.11.1995, U!'1ne culture (8) on 13.11.1995, 14.11.1995, 15.11.1995, 16.11,1995, 18.11.1995, 20.11.1995 and 22.11.1995 and drain culture (1) on 17.11.1995 were done at opposite party No.6-nursing home which were negative. Chart of investigations would indicate that blood culture (2) on 14.11.1995, U!'1ne culture (8) on 13.11.1995, 14.11.1995, 15.11.1995, 16.11,1995, 18.11.1995, 20.11.1995 and 22.11.1995 and drain culture (1) on 17.11.1995 were done at opposite party No.6-nursing home which were negative. Further, in opposite party No.4-hospital tests of blood on 21.12.1995 (2), 22.12.1995 (2), 6.1.1996 (2), urine on 21.12.1995,22.12.1995,27.12.1995, pus on 21.12.1995,22.12.1995,23.12.1995, 2.1.1996, MP on 21.12.1995, Oral Candida on 22.12.1995,20.1.1996 and 27.1.1996, AFB Sputum on 27.12.1995, 28.12.1995, Throat Swab on 22.12.1995, CMV on 26.12.1995, Chest X-rayon 26.12.1995 and 1.1.1996, Sputum Culture Bacteria :on 27.12.1995, Fungus on 27.12.1995 and 28.12.1995, CSF Culture Bacteria on 27.1.1996 and fungus on 27.1.1996 were done. Opposite parties, therefore, cannot be blamed for not having carried out the necessary investigations. It cannot be doubted that opposite party Nos. 1,5,2 and 3 had exercised, with reasonable competence, the skill they possessed in treating Naveen Kant post-operatively. Doctors treat the patient and the cure is in the hands of Almighty God. If. Naveen Kant who was having kidney problem since 1990 had not responded to the treatment and died on 3.2.1996, the opposite party doctors cannot be held negligent nor the opposite party-hospitals held deficient in service. Opposite party Nos'.4 and 7 -hospitals for the services rendered in the present complaint did not require registration under aforesaid Act of 1994. Complaint, thus, deserves to be dismissed being without any merit. Dismissed as such. No order as to cost. 25. We would like to place on record deep appreciation for the pains taken by the parties Counsel in conducting the case. Complaint dismissed.