RAJINDER SINGH NANDAL vs ANMOL HOSPITAL

THIS complaint has been filed by the complainants - Rajinder Singh Nandal and others being the husband and surviving children of the deceased Smt. Sushila Nandal, alleging medical negligence on the part of the opposite party hospital being opposite party No. 1 and the Doctor-in-charge being opposite party No. 2.

THE facts of the case are that the deceased, Smt. Sushila Nandal suffered from excessive bleeding some time in June-July, 1991 and in this context approached opposite party No. 2 who is also the proprietor of opposite party No. 1 hospital. THE deceased was advised by the opposite party No. 2 for surgery, i.e. removal of uterus which was carried out on 10.12.1991 in respondent hospital and was discharged on 20.12.1991. On developing stomach pains the deceased was again admitted in the opposite party hospital on 5.4.1992 where the deceased was diagnosed as having diarrhoea and vomiting. THE allegation is that knowing fully well that the deceased Smt. Sushila Nandal is a patient of sugar/diabetes and without controlling the same, she was administered 15/20 bottles of glucose till 10.4.1992 on account of which the condition of Smt. Nandal deteriorated and became so serious that the opposite parties, apprehending that the deceased will not survive, got her admitted in Sir Tirath Ram Hospital on 10.4.1992 where she died on the same day. THE cause of the death was opined to be ''Diabetes Ketoacidosis and peripheral circulatory failure''. THE allegation is that the deceased died on account of negligence solely attributable to the opposite party No. 2 and misadministration of opposite party No. 1 by administering glucose while knowing fully well that the deceased was patient of sugar/diabetes. THE complainant prays for an award of Rs. 11,33,676/- under different heads to the complainants 1 to 3 along with interest @ 24% p.a. and any other relief as deemed fit by this Commission. The respondent in their reply states that opposite party No. 2 was aware of the fact of the deceased suffering from diabetes. Since the main allegation is that the deceased was administered with glucose which led to deterioration to such an extent that she had to be shifted to Tirath Ram Hospital, it was stated by the respondent No. 2 that it is a well established fact that there is no absolute bar on administration of glucose to a diabetic patient. The sole precaution which need to be taken is that the dosage of glucose has to be neutralized with a corresponding dosage of insulin. In the instant case this, precisely, was done both at the time of surgery in December, 1991 and again in August, 1992. It is not the case of the complainant''s that glucose can never be given. In December, 1991 she was operated upon for histratomy which was done successfully and the deceased was discharged on 20.12.1991. She was readmitted in April, 1992 with Gasroentertics for which she was administered medicine as per medical norms and practice. There is no nexus between the glucose given during the hystractomy and glucose given for the gastroenteritis five months later. According to the respondent No. 2 the deceased was fit to be discharged on 8.4.1992 and hence was discharged as per records but could not go home as her husband did not came to pick up her. Since they know each other well for some time, deceased was allowed to stay in the hospital. Next day morning she started complaining of breathlessness for which respondent No. 2 called Dr. Bhargava who examined the deceased at about 9.30 a.m. and found her condition to be fair and advised continuation of the same treatment. The following morning on 10.4.1992, she again complained of breathlessness and difficulty in breathing for which she called Dr. Mathur, a Cardiologist, who saw the deceased at about 11 a.m. and advised her shifting to Tirath Ram Hospital in ICCU where Dr. Mathur is Consultant and she was shifted there at about 12.15 in the company of her neighbours. The deceased patient suffered from two cardiac arrrest which were beyond respondent Nos. 2''s care and control in Tirath Ram Hospital where she unfortunately died. A wrong impression is being attempted to be created that she died on account of diabetic Ketoacidoses, whereas a plain reading of death certificate issued by Tirath Ram Hospital clearly states that cause of death as peripheral circulatory failure. The latter is synonymous with heart failure. Any negligence on the part of respondents was denied. Allegations of negligence and irresponsibility alleged in the complaint was also denied. What was done for the deceased was as per medical practice hence no case of negligence is made out against the respondents, and in these circumstances, the complainant need to be dismissed. The respondent No. 2 also enclosed photocopy of the hospital record in support of her above averments.

In the rejoinder it is restated that the respondents were highly negligent in not neutralising the effect of sugar with insulin. All the medicine administered upon the deceased were purchased through complainant No. 1 and no insulin was ever got purchased, hence presumption is that it was not administered. It is also stated that surgery of hystractomy was not satisfactory as after a week of the surgery she developed complications; she had pus oozing out of one of the stitches used in the operation, and the condition improved after 10-15 days after taking treatment from the respondent but she was having occasional pain in the stomach for which finally she went back to the hospital on 5.4.1992. It is also stated that the deceased was shifted to Tirath Ram Hospital without informing and intimating the complainant No. 1 who had visited his wife in the morning but respondent No. 2 had assured of gradual improvement in the patient''s condition. The complainant had paid Rs. 25,000/- to the respondents for treatment. Records attached with the reply filed by the respondent is nothing but a manipulation prepared afterwards and reconstructed.

IN all, four affidavits were filed by the complainant by way of evidence. These were of the complainant himself and the rest three of the neighbours who helped in shifting the deceased patient to Sir Tirath Ram Hospital. On behalf of the respondent three affidavits were filed by way of evidence i.e. of respondent No. 2 herself and the two others of that of Dr. S.P. Bhargava and Dr. D.S. Mathur. In its affidavit the complainant reiterates that at the time of surgery done by the respondent No. 2 on the deceased in December, 1991, sugar was not controlled and without taking necessary measures for the same. Surgery was followed by complications and for which she had to be re-admitted in April, 1992, and that no specialist visited/examined the complainant''s wife either on the night of 9th or in the morning of 10.4.1992 and fearing the worst the deceased was shifted to Sir Tirath Ram Hospital, on 10.4.1992 through their neighbours and without informing him. The complainant denied of the deceased having any history of hypertension and in Tirath Ram Hospital Dr. Mathur asked them whether the respondents did not know that the deceased was a diabetic patient ? Deceased died on account of negligence on the part of the respondents. The three identical affidavits filed by the Phulwati Saroj Bala and Shashi Bala state that on the morning of 10th April 1992, not finding the complainant at home, the Nepali servant sent by the respondent No. 2 contacted them on being told of the state of health of the deceased reached the hospital, where they were forced to remove the deceased to Tirath Ram Hospital in a taxi without taking any precautionary measures. On reaching the Tirath Ram Hospital, deceased was taken to ICU where she died at about 10/11 p.m. on the same day and that respondent No. 2 was thoroughly negligent, inhuman and callous throughout the period of their stay with them.

IN her affidavit respondent No. 2 Dr. Sethi states that basically two allegations have been levelled against her, i.e. treating the known diabetic patient by administering glucose which finally led to her death and secondly, having operated upon the deceased in December 1991 without controlling diabetes. IN fact operation i.e. surgery for hystractomy was successful. When she came again on 5.4.1992 she was complaining of loose motions and vomiting. For controlling diabetes during the interregnum period she was under the treatment of another Doctor and was also taking Ayurvedic medicines from her village Doctor. For the rest of the allegation she reiterated the facts given in her reply and denied allegations of any negligence on her part. IN his affidavit Dr. Bhargava, a Physician with an M.D. degree states that he was called by the respondent No. 2 in the morning of 9.4.1992 to attend to her patient. On examination of the patient and her hospital record found the deceased condition to be fair, there was little breathlessness with occasional wheezing. Her BP and pulse were normal. He also saw that along with other medicines the deceased was being given insulin. He advised certain investigations and in the mean time advised continuation of medicines prescribed by the respondents. The witness states that he made contemporaneous notes of the examination of the deceased. IN his affidavit Dr. Mathur, a Cardiologist, states that he was called by the respondents on the morning of 10.4.1992 to examine the deceased. Since he found the deceased''s sugar levels high, he advised her to be shifted to Tirath Ram Hospital and till she reaches there, advised administering twentyfive units of insulin to her. He denies having ever told the complainant that the deceased was given glucose with neutralising it. During his cross-examination the complainant states that the deceased was consulting respondent 2 for treatment of diabetes. He admits that deceased was suffering from diabetes since 1998-89 and goes on to say that her diabetes was non-insulin dependent. For diabetes she was under treatment of one Dr. Bhatia who is a Physician at Inderlok. Complainant could not recall the tablets her wife was taking to control diabetes. He totally denied of any insulin being administered to the deceased before 1991. He denies that the deceased suffered from hypertension before December, 1991. Asked a specific question if a patient is given high dosage of glucose without balancing it, whether the patient shall not become comatose within six to twelve hours ? Complainant says he cannot answer the question as he is not a doctor. The complainant states again that no insulin was given ever to the patient in either of the two separate stays in the respondent hospital, the basis of this is that on reaching the Tirath Ram Hospital Dr. Mathur asked him ''Mr. Mandal, did the Doctor not know that she was suffering from diabetes ? Dr. Mathur also informed him that sugar level at present is 800 and due to that reason, all her systems failed'' - that was the basis. The other reason is that the complainant examined all the documents/prescriptions of the doctor and come to know that no insulin was given by the Doctor (Respondent 2). Based on his consultation with some other Doctors, Dr. Mathur''s above observations and prescriptions, he came to the conclusion that his wife died due to non-control of sugar. On being asked as to what material was shown to these newly found doctors, no satisfactory answer was forthcoming. It was only the prescriptions, which, according to the complainant, did not contain any reference to insulin, nor did he ever purchase insulin for his wife. The record now produced is a ''made out'' record. He admits that he did not file any prescription as they were with his wife who was shifted to Tirath Ram Hospital in a hurry - he found/got nothing from the hospital. He again states that when his wife was operated upon, in December, 1991 the doctor had daily and continuously given insulin in glucose and got her blood tested, but in April 1992 she was neither given insulin in glucose and got her blood tested, whereas in his complaint, allegation of ''negligence'' relate to both the periods. The complainant admits that he has no prescription of any visit after discharge from the hospital on 20.12.1991 as they are lost. On being asked, can the complainant distinguish between a bottle 5% glucose and bottle of ringers - answer is no. Confronted with para 8 of the legal notice sent by complainant through his Lawyer to the respondent wherein it is stated that the complainant came to know of the death of his wife in Tirath Ram Hospital after she had expired, ''reply is how is that possible'', he is unable to answer squarely. Complainant is unable to substantiate payment of Rs. 2,000/- earned by the deceased per month nor is he able to substantiate payment of Rs. 25,000/- the respondents. On being asked by the Bench the complainant is not able to give any satisfactory answer about the payments made either by showing any receipt or even the source i.e. from which Bank did he draw the money ? Death Certificate was collected three months after the death and only then did he come to know the cause of death. No satisfactory answers were forthcoming from the complainant on questioning by the Bench as to why when CGHS facility is available he was not getting his wife treated from there. Complainant admits now that for control of diabetes the deceased was under the treatment of their family doctor Dr. Bhatia, but no record of whatever nature, prescription, cash memo or any blood sugar test report is available. He is not sure whether Dr. Bhargava is a Physician or a Pathologist. On the question of manipulation of record he says "I cannot say which one is manipulated and which one of is genuine". In their cross-examination, Phoolwati states that she does not recall when her affidavit was taken. Mr. Mandal had taken me somewhere in connection with the affidavit but she cannot recall where ? Her cross-examination was only a set of denials as she cannot recall many things asked of her. She states that the deceased was unconscious when she reached respondent hospital and a taxi has been called and she was asked to go with the patient to Tirath Ram Hospital where Mr. Mandal arrived around 3.00 p.m. Witness Sashi Bala states that she was in village when she signed the affidavit, she cannot recall when Mr. Mandal reached Tirath Ram Hospital as she left immediately after the deceased admitted in the hospital. ''No precautionary measures were taken'' referred to in my affidavit meant no nurse accompanied us and no provision for oxygen was made. In her cross-examination respondent No. 2 admits that they were on social terms with the complainant''s family and had delivered one of their child in July, 1991, deceased came to her complaining excessive menstrual bleeding. Seeing her convenience of getting leave in December, she was operated upon for removal of uterus (hystractomy), on 10th December, 1991 and discharged on 20th December, 1991. Her blood sugar was got tested from Dr. Subhash Bhargava''s Laboratory in Daryaganj. On the Counsel for the complainant''s suggestion that at the time of operation the deceased''s urine sugar was 4 which would be equivalent to 360 mg., Respondent No. 2 states it will be less than 300 between 250 and 300 and she completely denies that urine sugar 4+ would be equivalent to 360 to 400 mg. and goes on to say that when the patient is going for surgery ''we always keep the sugar level a bit high so that they may not go in hypoglycemia. After that we adjust the dose when the patient is out of danger''. After the operation, sugar level started coming down and came to normal on 11th December, 1991. At the time of discharge blood sugar fastening was 105 and pp was 160. Counsel for the complainant''s suggestion that on prescription she wrote the patient wants to take her own Ayurvedic medicine'' has been written by respondent No. 2 to corroborate her reply, is denied. Witness concedes that she is unable to produce the record or other Doctors who helped her at the time of surgery. Witness states that they do not maintain any OPD register but give a card to OPD patients; the deceased visited her about five times in January, 1992 after the surgery in December, 1991. Then, the questioning goes on about the two different names the hospital carry Doctor Lata Maternity & Gynae Clinic and Anand Hospital. It is then the Bench tries to bring the case back on the rails by suggesting to the Counsel for the complainant that he has to prove his case of ''negligence''. The President tells the Counsel for the complainant that : Dr. Mathur has already appeared and has stated that sugar level of 200 or 300 normally does not hurt. If the blood sugar level is high continuously normally all the organs of the body may get damaged, kidney, heart, eye, etc. That is a long terms effect. If it is not kept under control then heart attack comes about, you will have to prove that "Counsel for the complainant goes on to say that they were not given discharge certificate at the time of discharge on 20.12.1991 and not again on 10.4.1992 as the deceased was shifted to Tirath Ram Hospital and not discharged as such. The averment is to draw a reflection on the record produced based on the conduct of respondent No. 2 about changing the name of the hospital 4/5 times, even though this is not the grievance made. In reply to question of hypertension it is stated that this is a stage when blood pressure goes up - in the case of deceased the normal blood pressure was 130.8.1984 below 90. On 5th April, she came alone in a rickshaw. After admission her urine sugar was tested six hourly and blood sugar was got tested twice, i.e. on 7th and 10th April, 1992. She had shown considerable improvement on 8th April, and was fit to be discharged; her pulse was 88, temperature normal, no loose motions and no vomiting. After discharge she did not go home as she wanted to go with her husband, who did not come that day. In fact, he did not visit the respondent hospital again till the time of shifting to Tirath Ram Hospital. Deceased was shifted on the advice of Dr. Mathur. On 10th Dr. Mathur had observed in the respondent hospital after examining her that she has settled the blood pressure, pulse and respiration were comfortable. Respondent No. 2 denies having prepared the record later on in consultation with expert doctors. It is conceded that no blood sugar tests were done except on 7th and 10th April, 1992. No report of 10th April, 1992 is available as the patient had already shifted to Tirath Ram Hospital. It is the patient who pays for the report, Doctors see it only during their rounds and reports remains with the patient. In his cross-examination Dr. Mathur states that he was familiar with the patient having seen her once before i.e. in December, 1991 and was generally aware that she had diabetes. Again when he reached hospital at about 11.00 a.m. on 10.4.1992, the deceased was breathless, she was taking respiration with difficulty, urine was showing 2+ ketone and 4+ sugar. He had suggested her to be shifted to Tirath Ram Hospital, as he is a consultant there. Urine sugar was 4+, and when urine sugar showing ketone also that means, patient''s sugar is high. But, seeing her condition I had advised her shifting to Tirath Ram Hospital. She was breathing little high. She was having temperature be cause of some infection and in diabetes-chest infection is very common. The patient was not unconscious. She answered her questions. She was little drowsy, was able to talk for about ten minutes and becoming drowsy for twenty minutes. Witness rebuts that at any time deceased patient''s sugar was 800 mg. He recorded the deceased''s sugar level being 250-300 at the time of admission in Tirath Ram Hospital and it was brought down by the medicine insulin. He completely denies ever having told the complainant that did not respondent No. 2 know that the deceased was suffering from diabetes ? Ketoacidosis means ketone having started coming in the urine of a patient of diabetes. In his examination-in-chief, the expert witness Dr. R. Goswamy states that on the day of operation for hystractomy on 10.12.1991 that firstly the deceased was administered glucose along with insulin and secondly ''I do not think that there was major problem with insulin management in the first operation''. Witness also states that when a patient comes to the hospital with vomiting and gastroentritis and the patient is known to be a case of diabetes then we always look for ketotis. He also states that at the time of admission on 5.4.1992 blood sugar test should have been done when a patient gets operated. On a specific question been asked about any negligence on the part of the respondents during her second visit to the respondent hospital between 5.4.1992 and 10.4.1992, the witness states that he cannot see any negligence upto 8.4.1992. On 9th her (deceased) condition started deteriorating. On being specifically asked by the Bench ''can you say that death was because of wrong management of blood sugar'', reply is, ''definitely not'', till 8th she was getting insulin, sugar was controlled, even on 9th urine sugar report is ''green'' at 6 p.m., which means she was not having severe ketotis. Ketones were there, but in traces, if we had blood sugar value, that would have helped. "nottacking blood sugar was (being negligent)" but did not lead to her death. His final conclusion is that if ketones are + blood sugar value 200 then there is no danger. He also states in his examination that 4+ urine sugar means more than 200 mg. presented in blood, there is no fixed value which can be read from 4+. There is no cut-off. It varies from person to person. 180 is the normal range from which onwards they start showing urine sugar plus, after 180, it can be 1+, 2+, 3+, it depends upon person to person. Minimum, it should be 200.

IT was argued by the learned Counsel for the complainant, Rana Ranjit Singh that their main grouse is that the deceased was administered over-dosage of glucose both at the time of surgery on 10.12.1991 and again at the time of second admission during 5.4.1992 to 10.4.1992 without balancing it with insulin, which is ''negligence'' on the part of the respondent leading to the ultimate untimely death of the complainant''s wife at an early age. On 10.12.1991, respondent No. 2 carried out operation without controlling sugar which was 4+. Even after discharge on 20.12.1991, the deceased continued to have problem for which she had to visit the respondent hospital regularly. Again during the second admission of the deceased in the respondent hospital on 5.4.1992 she was administered about 15/20 bottles of glucose without neutralising it with proper doses of insulin as a result of which on 10.4.1992 sugar level became so high that her position deteriorated beyond control and after consulting Dr. Mathur she had to be shifted to Tirath Ram Hospital that too without taking any precautionary measures. She was handed over in an unconscious condition to the neighbours to be taken to the Tirath Ram Hospital where she died on the evening of 10.4.1992 on account of negligence on the part of the respondent while the deceased was under the care of the respondent Nos. 1 and 2. IT was also argued by him that records have been doctored and manipulated afterwards. Respondents'' conduct can be judged from the several names of the respondent hospital which the respondent has been changing and at times carrying more than one name (four to five names) at the same time. He drew our attention to the evidence on record of respondent No. 2 and especially of expert witness Dr. Goswami as well as of Dr. Mathur who has stated that not taking blood sugar of the deceased is a case of negligence. On account of all this, the learned Counsel vehemently argued that these are series of negligence on the part of the respondents which led to the death of the deceased Smt. Shushila Nandal in view of which the complaints be allowed in full. He relied on Lakshman Balakishan Joshi v. Triambak Babu Gadbole and Anr., 1969 (1) SCR 206, in which the Hon''ble Supreme Court held : "A person who holds himself out ready to give medical advice and treatment holds forth that he is possessed of skill and knowledge for the purpose. Such a person when consulted by a patient, owes certain duties, namely, a duty of care in deciding whether to undertake the case, a duty of care in deciding what treatment to give and a duty of care on the administration of treatment. A breach of any of the duties gives a right of action of negligence against him...". The judgment of the Hon''ble Supreme Court delievered in Acutarao Hariban Khadwa and Ors. v. State of Maharashtra and Ors. reported in I (1996) CLT 532 (SC)=1996 (2) SCC 634, as also relied upon by the learned Counsel for the complainant wherein it was held, "a medical practitioner has various duties towards his patient and he must act with a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. This is the least a patient expects from a Doctor ... Courts would indeed be slow in attributing negligence on the part of the Doctor if he has performed his duties to the best of his ability and with due care and caution ... As long as Court finds that he has attended on the patient with due care, skill and diligence, and if the patient still does not survive or suffers a permanent ailment, it would be difficult to hold the Doctor to be guilty of negligence. But, in cases where a doctor acts carelessly and in a manner which is not expected of a medical practitioner, then in such a case, an action of torts would be maintainable".

ON the other hand, it is argued by the learned Counsel for respondent, Mr. Bajaj that respondent No. 2 has specialised in Gynaecology and Obstretitis and was qualified to carry out the surgery which she performed on the deceased on 10.4.1992 and was discharged on 20.12.1992. Her blood sugar levels were always kept under control and monitored regularly. The complainant himself has stated in his cross-examination that the deceased was getting insulin regularly along with glucose in December, 1991. Deceased remained all right for the next about 4 months. Again on 5.4.1992 the deceased reported to the hospital on account of vomiting and loose motions and was administered glucose with insulin and her urine was monitored round-the-clock. It is now admitted even by the specialist witness that all was well till 8.4.1992 and on the morning of 9th April, when the deceased reported breathlessness, she was seen by a specialist Doctor Bhargava who advised certain tests but otherwise to continue to give the same medicine as were already being administered as prescribed by respondent No. 2. ON 10.4.1992, when the deceased again complained of breathlessness and also had perspiration. Respondent No. 2 called Doctor Mathur who is a Cardiologist and who examined the patient at about 11.00 a.m. on 10.4.1992 and as per his advice administered 25 units of insulin and then shifted her to Tirath Ram Hospital by about 1.00 p.m. or so. Dr. Mathur also states in his cross-examination that at the time of admission in Tirath Ram Hospital sugar level of the deceased around 250 or 300 which was brought down further by medicine insulin. This all shows that respondents has taken every reasonable care and precaution to ensure safety of the patient. He also met the point regarding allegation of the complainant, that Dr. Mathur in Tirath Ram Hospital enquired from him if respondent No. 2 did not know that the deceased was having diabetes ? Dr. Mathur unequivocally has denied this. He also challenged the income of the deceased. Medical literature on the subject was also produced by him before us in his support. In "Current Concepts in Diabetes Militus'' by (Hon. Lt. Col.) Gurmukh Sawami, Emeritus Professor of Medicine, Grant Medical College, Bombay, it is stated that ''The Framingham Heart Study has shown that there is a higher incidence of CAD in diabetes and that the prognosis is poor in them. Cardio Vascular mortality is twice as high in men and four times as high in women who have D.M. compared with their no diabetic counterparts'' ... in diabetes, immediate per-infarction mortality is high. Diabetic women have increased mortality (nearly twice in hospital mortality in women as compared to men). In ''International Text Book of Diabetes Mellitus'' Volume -2 published by John Willy & Sons, Chicester, New York, it is stated that "Diabetes mellitus brings with it a substantially increased risk of large vessel disease. In diabetes men mortality from cardio-vascular disease is approximately doubled and in women relative risk is higher". In ''Joslinis Diabetes Mellitus''-13th Edition Lea & Febiger-1994, it is stated : "The principal advantages of urine testing are its simplicity and low cost. It is still useful for patients with limited goals for glycemic control for those unwilling or unable to perform blood glucose monitoring. Urine testing done well is more valuable to the care of the patient than is blood testing done poorly-"

In Oxford Text Book of Medicine Volume I - Sections 1 to 12, Oxford University Press, Second Edition, 1987, it is stated that : Monitoring of Theraphy Urine testing for glucose has been the cornerstone in assessing metabolic control for over 50 years. Urine Ketones Urine Ketones need not be measured routinely in the majority of Type I or any type of II diabetes. Blood Glucose : Blood glucose measurement is the obvious test to glycemic control but a spot sample gives only momentary information. In ''Diabetes in the Real World'' Class Publishing, London, It is stated that : Advantages of testing Urine Vs testing Blood Urine testing is non-invasive. Urine testing is inexpensive. There is less room for error. According to the literature, the method adopted by respondent to monitor sugar levels were in order. The two reports of blood sugar dated 7.4.1992 and 10.4.1992 of Dr. S. Bhargava, M.D., Pathologist, shows blood sugar random level of 160 mg. and 170 mg. respectively. No case of negligence has been proved against the respondent and in these circumstances a plea was made to dismiss the complaint with costs.

We have heard the arguments and perused the material on record and find that the whole basis of complaint is that glucose was administered to the patient without neutralising both at the time of surgery in December, 1991 and again during the second visit from 5.4.1992 to 10.4.1992.

ON perusal of material on record we find that there is only a passing mention in the complainant about the surgery having been performed on the deceased on 10.12.1991 without fully controlling the sugar levels. There is no complaint that there was any problem with surgery or there was any recurrence of bleeding or any gynic problem. Expert Witness Dr. Goswami clearly states in his examination that ++++ sugar levels does not mean much and on specific question, Whether she (deceased) could have been operated upon with the blood sugar available on the date ? The expert witness states that ''she could have been operated very well in such conditions''. The next allegation, of insulin not having been administered along with glucose is not substantiated by the evidence tendered by the complainant himself when he says that insulin was being given along with glucose. The complainant in his cross examination admits that "I know that in December, 1991, when my wife was operated upon, the doctor has daily and continuously given insulin in glucose and she got her blood tested in the lab every 2-3 days". It is an admitted fact that she was coming to the respondent hospital after the surgery in December, 1991. But, that it was in connection with the problem of pus in stitches and stomach pain. But no record is available or produced before us about the visit of the deceased to the respondents on the cause of these visits and treatment administered. Based on the statement of the complainant himself and that of the expert witness we are not inclined to see any nexus before surgery and the latter complication. It is an admitted fact the deceased came to the respondents, second time on 5.4.1992 complaining of vomiting and loose motions which is symptomatic of gastroenteritis which results in dehydration and it is not uncommon that in such situations, the patient is administered ''drip'' of glucose. In this case, since the deceased patient was a known case of diabetes, insulin was also administered. It is the case of the complainants that no insulin was administered. It is the case of the complainants that no insulin was administered to neutralise the 15/20 bottles of glucose given to the deceased. It is also their case that the record has been doctored and manipulated and made up in consultation with some expert doctors. In reply to a specific question reply of the complainant in cross-examination as recorded by the Bench is "I cannot say which (record) is manipulated and which one is genuine" and goes on to say that any one can indicate which part of record is genuine or otherwise. Then he says only a hand writing export can do so. We are unable to accept this line. The complainant is also not able to show us as to which portions are manipulated. In the absence of this, we are unable to lend any weight to this specious plea of the complainant that some part of the records are manipulated, as nothing is proved in this regard; mere indication of a suspicion is not proof hence we would like to reject this contention. The complainant''s statement in his examination is that he knows for sure that no insulin was administered to the deceased as he did not purchase insulin. He also states, that ''six or seven months after the death of my wife, I examined all the documents, prescriptions and other documents of the doctor. Then I came to know that no insulin was given by the Doctor''. Then he goes on to say that his deduction of non-administration of insulin is based on "the prescriptions, on the advice of any doctors and on the sayings of Dr. Mathur on 10th. He then goes on to admit that he has no prescriptions; we also see that Dr. Mathur during his cross-examination unequivocally denies having ever told Mr. Nandal, the complainant, about the non-administration of insulin by the respondents. Asked what was the material shown to his ''doctor'', on the basis of which his doctors stated that insulin was not administered, the complainant was at sea. No specific answer is forthcoming from him. On the basis of the record, we are unable to concede the point and agree with the complainant that insulin was administered along with glucose to the deceased, during her stay in the respondent hospital during 5th April to 10th May, 1992. Record clearly shows - noted in the margins - that insulin in fact was administered. A sustained attempt was made by complainant''s side to cast a doubt about the conduct of the respondent''s by series of questions relating to frequent change of name of respondent hospital. We find that this was an unwarranted attempt and Bench was constrained to observe that had they known that such is the intent of the complainant then they would not have permitted such questions to be asked of respondent No. 2, Firstly it is not part of the pleading and secondly nothing, as far as medical negligence is concerned, turns on it. We find no merit in this.

THE expert witness is clear that whatever was the line of treatment till 8.4.1992 no negligence is made out. Same thing happened during the last two days, i.e. 9th and 10th. He also says not taking blood sugar was on act of negligence. THE sequence of events is that on 9th the deceased complains of breathlessness a Physician/Cardiologist Dr. S.P. Bhargava is called in who examines the patient at 9.30 p.m. THE patient was conscious and her general condition was fair, B.P. was 120/80, pulse at 100. He advised certain investigations and also advised continuing the same treatment which respondent No. 2 was administering. Blood was taken on the 10th for measuring blood sugar, but the deceased again complained of breathlessness and respiration with great difficulty, on the 10th morning common factors associated with cardiac problems. Another Cardiologist Dr. Mathur is called who examined the deceased at about 11.00 a.m. who after examination saw that patient''s sugar is high which was shown by the presence of keton in the urine. Based on the general condition of the patient Dr. Mathur suggested her to be shifted to Sir Tirath Ram Hospital where Dr. Mathur was a consultant. Not finding the complainant at his residence, she was sent to Tirath Ram Hospital in the company of three of the neighbours of the complainant. Unfortunately, Dr. Bhargava has since died, hence, could not come to the witness box. Dr. Mathur in his cross-examination states that she (deceased) was taking breathing little high, she was having temperature (because of some infection) and in diabetes chest infection is very common. It is in these circumstances that he advised her shifting to Tirath Ram Hospital. When she reached the hospital she was little drowsy, not semi conscious, her sugar levels were around 250-300 which was brought down in the hospital by administering insulin. He admits that the deceased died on account of ketones. We find nothing wrong in the sequence. As long as she (deceased) was all right, respondent 2 was treating her i.e. till 8th but when she observed breathlessness, natural concern is cardiac problem ? and she called a cardiologist Dr. Bhargava and again the next day Dr. Mathur, again a cardiologist. Respondent No. 2 did precisely what the Hon''ble Supreme Court has laid down in the parameters of duties of a Doctor. When the deceased came to the respondent hospital on 5.4.1992 she was having gastroenteritis. It is not the case of the complainant that vomiting and loose motions did not stop. THEy did. When the breathlessness and related problem arose which was beyond her competence, respondent No. 2 called the expert in those fields, no negligence can be attributed in this regard. Respondent No. 2 did bring in our view than a reasonable degree of skill and knowledge in taking care of the deceased. There are two other points raised; one relates to the statement of expert witness that not taking blood sugar levels was a negligence. In our view, enough material by way of medical literature has been shown to us - reproduced earlier - to meet this point. Be that as it may, the crucial point made by the expert witness in conclusion is that ''if ketones are plus, blood sugar value 200, then there is nothing danger'', in her cross-examination, respondent No. 2 states that the test for blood sugar was done on 7.4.1992 and 10.4.1992 and the result was 160 mg. and 190 mg. random. This has since been brought on record. This was not challenged by the complainant. Therefore, taking these figures of blood test and the statement of the expert witness, the obvious deduction is that deceased was in no danger even on 10th. It is important to note that as per the medical literature vulnerability of the deceased patient and more so, the woman, a diabetic patient, to cardiac related problem is very high. Another point of negligence alleged by the complainant is that at the time of shifting of the deceased to Sir Tirath Ram Hospital, precautionary steps were not taken by the respondent like providing a nurse or oxygen, etc. We find some merit in this and this has not been rebutted by the respondents. But, we also see nothing turns on this any way. The deceased reached Tirath Ram Hospital and according to the complainant''s witnesses they were carrying a slip for admission and the deceased was admitted after an hour and a half but when Dr. Mathur saw her, she was conscious but little drowsy, blood sugar was around 250-300 and not 800 as alleged by the complainant. It would have been desirable had some Nurse come with her, this would have become material if something had happened en route. Nothing happened, hence no negligence stands our scrutiny. Keeping in view of the sensitivity of the case we refrain from commenting upon the source of payment made in cash by the complainant on which the Bench put a lot of questions to him, or his not producing Dr. Bhatia, i.e. the complainant''s Doctor (he does not know whether he is a Pathologist or Physician) under whose care deceased was, for treatment of diabetes and with whom perhaps record of diabetes/various tests could have been, we also refrain from commenting on the complainant''s unwillingness to go to C.G.H.S. on which Bench asked large number of questions.

BASED on the material on record, we are quite clear that due diligence, care and attention was given to the deceased by the respondents and they were possessed of skill and knowledge to deal with the nature of complaints with which the deceased reported to the respondents. In our view, no case of medical negligence has been made out or proved. The complaint is dismissed. Keeping in view the facts and circumstances of this case no order on costs. Complaint dismissed.