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Dengue Update

Taken from forwarded email-seems to authenticated. Please exercise due caution while utilizing this article.

New serotype of dengue

* Dengue normally are of Den1, Den2, Den 3 and Den4 serotypes

* Serotypes 1 and 3 are less dangerous as compared to 2 and 4

* This year its serotypes 2 and 4 which are prevalent

* As per AIIMS the type 4 strain of the disease has emerged as the dominant type for the first time in the capital, along with dengue type 2

* Symptoms of type 4 dengue include fever with shock and a drop in platelets, type 2 causes a severe drop in platelets, haemorrhagic fever, organ failure and dengue shock syndrome

* Every strain carries the risks of hemorrhagic fever, but type 4 is less virulent than type 2. Risk of severe dengue is highest with dengue-2 viruses

* Doctors were expecting the strain to change this year, given the large number of cases. Doctors were not expecting type 4 because it has never been actively circulating in Delhi

* When the dominant strain remains the same for a long period, a significant population develops immunity to it, and fewer patients are diagnosed with the virus. However the type 4 strain had never even shown a significant presence. A new serotype will always end up with an epidemic like situations

* Infection with one of the four serotypes of dengue virus (primary infection) provides lifelong immunity to infection with a virus of the same serotype. However, immunity to the other dengue serotypes is transient, and individuals can subsequently be infected with another dengue serotype (secondary infection). Subsequent infection with a second type increases the likelihood of serious illness

* The risk for severe dengue appears to decline with age, especially after age 11 years

* AIIMS lab is also suspecting a new serotype this year in addition. Is it Dengue 5? Researchers screening dengue viral samples found a virus collected during an outbreak in Malaysia's Sarawak state in 2007 that they suspected was different from the four original serotypes. They sequenced the virus and found that it is phylogenetically distinct from the other four types. Experiments found that monkey antibodies produced against the new type differ significantly from those resulting from the previously known dengue viruses. So far, dengue 5 has been linked to only one outbreak in humans

* In 1996, when an outbreak of the disease was reported in Delhi with over 10,000 cases, the relatively severe type 2 strain of the virus was identified as the most common one

* In 2003, when a sharp rise in dengue cases was again reported, type 3, a mild strain, emerged as the most common type

* In 2013, with over 5,500 cases, type 2 returned as the common strain in the capital

* Most dengue patients are not serious

* Dengue is both preventable and manageable

* The risk of complications is in less than one per cent of dengue cases and, if warning signals are known to the public, all deaths from dengue can be avoided

* A platelet transfusion is not needed unless patient has active bleeding (other than petechiae) and platelet counts are less than 10,000

* Unnecessary platelet transfusion can cause more harm than good

* Classic dengue fever is an acute febrile illness accompanied by headache, retro orbital pain, and marked muscle and joint pains. Symptoms typically develop between four and seven days after the bite of an infected mosquito. The incubation period may range from three to 14 days. Fever typically lasts for five to seven days. The febrile period may also be followed by a period of marked fatigue that can last for days to weeks, especially in adults. Joint pain, body aches, and rash are more common in females

* Most complications of dengue occur after the fever is over. The two days after the last episode of the fever are crucial and during this period, a patient should be encouraged to take plenty of oral fluids mixed with salt and sugar

* The main complication is leakage of capillaries and collection of blood outside the blood channels leading to intravascular dehydration. Giving fluids orally or by intravenous routes, if given at a proper time, can save fatal complications

Only these need admission

* "Warning signs" - World Health Organization (WHO) guidelines recommend attention to clinical warning signs for severe dengue

* Severe abdominal pain or tenderness

* Persistent vomiting, lethargy or restlessness

* Abrupt change from fever to hypothermia

* Bleeding, pallor

* Cold /clammy extremities

* Liver enlargement on physical exam

* Abnormal mental status

Early recognition

* Dramatic plasma leakage often develop suddenly; therefore, substantial attention has been placed on early identification of patients at higher risk for shock and other complications

* The period of maximum risk for shock is between the third and seventh day of illness. This tends to coincide with resolution of fever. Plasma leakage generally first becomes evident between 24 hours before and 24 hours after defervescence

* An elevation of the hematocrit is an indication that plasma leakage has already occurred and that fluid repletion is urgently required

* Low platelet count usually precedes overt plasma leakage

* Mild elevations in serum SGOT and SGPT levels are common. Bit in severe dengue the levels are very high with SGOT > SGPT levels

* A normal SGOT levels is a strong negative predictor of severe dengue even in the first three days of illness

* NS 1 of >600 ng/mL suggests severe dengue

* Coexisting medical conditions, such as pregnancy, infancy, old age, obesity, diabetes mellitus, renal failure, and chronic hemolytic disease may increase the risk of severe dengue and/or complicate management. Referral for hospitalization is recommended for such patients, regardless of other findings

* Additionally, hospitalization should be considered for patients who may have difficulties with outpatient follow-up or with timely self-referral should complications develop (eg, patients who live alone or who live far from a healthcare facility without a reliable means of transport)

* Patients with suspected dengue who do not have any of the above indicators probably can be safely managed as outpatients, as long as close clinical observation is assured. Daily outpatient visits may be needed to permit serial assessment of blood pressure, hematocrit, and platelet count

Government may clarify: Is it an epidemic?

* Recent government circulars say: Postpone routine surgeries to accommodate dengue patients/ Postpone routine admissions/ Make provision of extra beds/ Do not refuse any patient who needs admission

* These all are done when an epidemic is announced

* In an epidemic all cases are presumed to be dengue, no confirmatory testing are done, a triage announcement is done, clear cut directions are announce regarding which patients are to be admitted and which patients re not to be admitted'

Management of significant bleeding

Gastrointestinal bleeding, epistaxis, or menorrhagia in patients with severe dengue (and occasionally in patients with dengue fever) can be severe enough to require blood transfusion

Blood replacement should be performed with 5 mL/kg of packed red blood cells (or 10 mL/kg whole blood)

Platelet transfusions have not been shown to be effective at preventing or controlling hemorrhage but may be warranted in patients with severe thrombocytopenia (< 10,000/mm3) and active bleeding

Prophylactic platelet transfusions in patients with severe thrombocytopenia but without active bleeding are not recommended

Fluid requirement

* 20 ml/kg body weight as bolus * 10 mL/kg over the next first hour * 7 mL/kg/hour for next two hours * 5 mL/kg/hour for next four hours * 3 mL/kg/hour for next 8 hours

Assessment

* Must pass urine every three hours * Duration of extra fluids * The fluids that are lost into potential spaces (eg, pleura, peritoneum) during the period of plasma leakage are rapidly reabsorbed * Intravenous fluid supplementation should be discontinued once patients have passed the period of plasma leakage * Usually no more than 48 hours of intravenous fluid therapy are required * Excessive fluid administration after this point can precipitate hypervolemia and pulmonary edema

When to discharge

In the absence of complications from prolonged hypotension or from medical interventions, most patients with severe dengue recover within a few days of admission No fever for at least 24 hours Two days have passed after an episode of shock Patient is clinically well Normal normal appetite, urine output, and hematocrit

No aspirin

Patients with dengue should be cautioned to maintain their fluid intake to avoid dehydration and to take paracetamol as needed for fevers and myalgias. Aspirin or nonsteroidal antiinflammatory agents should generally be avoided.

Compiled by

Arun shah 

Facts and figures about Crosspathy

Crosspathy:

Article courtesy:

DR.C. SRINIVASA  RAJU

Chairman -   Hospital Board of India - IMA AP STATE.

Member-crisis management committe-IMA H.Q.

NR PET

ELURU

A.P.

The present times?

Verma et al. conducted a survey of OPD prescriptions of a tertiary care allopathic hospital and an ayurvedic hospital, both belonging to government setup.

 The study found that the prescriptions from tertiary care hospital had 12% ayurvedic drugs, while prescriptions from ayurvedic hospital had 58% allopathic drugs.

In 2010, “The Common Review Mission (CRM) of the Union health ministry which came to one of the  states, to review the National Rural Health Mission (NRHM) has suggested the state government to depute Ayush doctors at the primary health centres (PHCs) if doctors are not available in the state.”

Is it legal?

No.

Is it justifiable?

No.

Primary health centres have allopathic medicines. Will these doctors from Ayush group prescribe allopathic drugs about which they are not well acquainted or their own medicines or alternatively prescribe medicines from two systems i.e. allopathic and their own system?

In case a serious adverse reaction occurs following allopathic drug administered by Ayush doctor, he/she may not be able to handle the situation appropriately. Who shall be held responsible in such a situation: Ayush doctor or the appointing authority?

Who is a Genuine Medical Practitioner?

Any individual who has acquired a qualification / degree from an institute which is recognised by its registering authority, like Medical Council of India, Dental Council of India, Homoeopathic, Ayurvedic or Unani System of medicine, and is registered with respective authority is a genuine medical practitioner for that specific system.

 In case an individual acquires degrees for two different systems, eg, a person who had passed BHMS and later studied and passed MBBS examination, can practice homoeopathy as well as allopathy provided he/she is registered with both authorities. All other persons should be treated as quacks or fraudulent medical practitioners.

Who is the quack?

According to Supreme Court any person who claims to be expert is a quack unless he has an adequately standardised training / qualification for these supposed / specific specialties

What is the difference between ANMs,compounders and Community Health Workers?

The issue regarding community health workers prescribing or dispensing some medicines is very relevant and pertinent.

 A compounder, nurse or auxillary nurse (ANM) has to pass examination after a stipulated period of training of 3-4 years, and then is supposed to administer any medicine which has been prescribed or advised by a doctor. Compounders and nurses are not permitted to administer any medicine on their own.

But, community health workers are permitted to administer some medicines by themselves.

So, It would be pertinent to have opinion of legal experts on this issue.

What is modern medicine?

The modern medicine is evidence based, peer reviewed, technologically assisted, preferred by meritorious students and hence probably more accepted.

Is there any difference between clinical care and clinical research?

Yes!

The Supreme Court forbids prescription or administration of drugs from other systems but research is not forbidden.

Any person who prescribes a drug from other system is liable for legal action by a court of law and suitable punitive action by respective authority like Medical Council of India, Dental Council of India, etc.

 An allopathic doctor cannot prescribe Liv 52 or Calcaria Phos, very popular ayurvedic and homoeopathic drugs respectively. Similarly, a vaid or a homoeopath cannot prescribe Amlodipine in hypertension, Valproic acid in epilepsy and any antibiotic

What is valid legal prescription?

Supreme Court is very stringent against crosspathy: the apex court laid out few directions about issuing the valid prescription.

The honorable SC in, C A no. 3541 of 2002, Martin F. D’Souza vs. Mohd. Ishfaq has observed that:

·         No prescription should ordinarily be given without actual examination.

·         The tendency to give prescription over the telephone, except in an acute emergency, should be avoided.

·         A doctor should not merely go by the version of the patient regarding his symptoms, but should also make his own analysis including tests and investigations where necessary.

·          A doctor should not experiment unless necessary and even then he should ordinarily get a written consent from the patient

Which Products can be prescribed by anyone?

The products which are food supplements can be prescribed or purchased by any one, because no prescription is required. Thus over the counter (OTC) drugs like Strepsil, Vicks, Hajmola, Ferradol, Sharkoferrol, Chyavanprash and protein preparations can be prescribed by any one.

What is the drug’?

The word drug is derived from the French word ‘drogue’ a dry herb.

Drug is defined as any substance used for the purpose of diagnosis, prevention, relief or cure of disease in man or animal.

According to WHO “a drug is any substance or product that is used or intended to be used to modify or explore physiological systems or pathological states for the benefit of the recipient.

According to The Drugs and Cosmetics Act, it includes all the preparations, whether allopathic or ayurvedic.

Who can handle drugs-sale,distribution,etc?

A drug can be sold or supplied by the pharmacist or druggist only on the prescription of a “registered medical practitioner” defined under Indian Medical Degrees Act of 1916.

What are the Licensed Herbal Products ?

Some therapeutic indices mention group of ‘licensed herbal products’ under many sections. Bonnisan is mentioned under section drugs for gastrointestinal system, Liv52 under section drugs for hepatic disorders, Abana is mentioned under section drugs for cardiovascular system, Eves Care for menstrual disorders, Septilin as Immunostimulant in various infections.

Does Allopaths are permitted to prescribe Ayurvedic drugs mentioned under licensed Herbal Preparation?

Yes/no-ambiguity!

Is it legal, that some private hospitals employ Ayurvedic or Homoeopathic doctors as resident medical officers under supervision of consultants?

It’s illegal . This could be considered fraud with the patients who attend that hospital for allopathic treatment by allopaths.

Even though, these AYUSH persons are trained and qualified personnel and as  their observations may be accurate but they have to administer allopathic medicines as advised by the consultant as like any compounder or nurse. Then it’s apt to appoint nursing staff who are well trained in allopathic system.

So,don’t appoint the AYUSH persons as RMOs in modern medicare hospitals.

 Wider discussion and larger platform:

So there is a urgent need for the Government, judiciary and Medical Councils to look into these vital issues and to frame clear cut guidelines keeping in mind the situation and facilities in our country..

There shouldn’t be confusion or paradox in legal, ethical or evidence based scientific recommendations.

This is important so as to prevent / decide the cases of medical malpractice and negligence in future.

At any cost,we must stop the crosspathy.

Role of IMA?

  Circular by the Union Health secretary requesting the state Governments entertain AYUSH to practce modern medicine.

IMA  filed the petition against this federal order.

IMA has to create the platform to converge all stake holders and extract legitimate conclusion once for all.

FAVORING CROSSPATHY	Opposing crosspathy
The other side(govt side ) of this issue is ------- That in many developing countries where rural health is important and qualified practitioners are not available the authorities are appointing community health workers (CHW). These CHW are provided with some of the common medicines which can be used for domiciliary management of common illnesses. Do they have the deep and complete knowledge of these illnesses or medicine? If an unqualified CHW can prescribe or dispense medicines why a graduate in medical curriculum (traditional or homoeopathic) cannot do so?	“The Apex Court in the Poonam Varma vs. Ashwin Patel case has ruled that if you are practicing any other system it is Negligence per se. In judiciary the decision of SC will always be binding on lower courts unless and until SC reviews its decision
Paradoxically, some High Courts eg. Tamilnadu HC (Tamil Nadu Siddha Medical Graduates Association, Vs. Smt. Letika Saran, Cont. P. No. 775 of 2010 decision dated 23.07.2010) and State commissions (Manpreet Kaur Vs. Dr. Veena Ghumber I 2005 CPJ 63) have pronounced that a practitioner of Indian system of medicine can prescribe drugs of modern medicine	S u p r e m e C o u r t j u d g e m e n t : A person can practice only that therapy for which he/she has a degree / recognised qualification or experience.  Medical Council of India. Clause 1.1.3 of MCI prohibits the allopathic practitioners to prescribe ayurvedic or homoeopathic drugs.

Running clinic is not a commercial activity

Forwarded message from whatsapp group.

IN THE HIGH COURT OF JUDICATURE AT BOMBAY

CRIMINAL APPELLATE JURISDICTION

CRIMINAL WRIT PETITION NO.1731 OF 2002

Dr.(Smt.)Shubhada Motwani ...Petitioner

vs.

The State of Maharashtra & Ors.

...Respondents

Mr.S.C.Naidu i/b.C.R.Naidu, Advocate for the

petitioner

Mrs.M.M.Deshmukh, APP, for the State.

Mr.Jamdar, Advocate for Respondent No.4

CORAM : V.M. KANADE &

P.D. KODE JJ.

JUNE 12, 2014

P.C. :-

1. By this petition, which is filed under

Article 226 of the Constitution of India,

Petitioner has challenged section 7(1) of the

Bombay Shops and Establishments Act, 1948. The

petitioner is a medical practitioner who is

duly registered under the provisions of

Maharashtra Medical Council. Show cause notice

was issued to the petitioner for not obtaining

a license under the Bombay Shops and

Establishments Act,1948 and criminal

prosecution was launched against her for

contravention of Section 7(1) of the said Act.

Bombay High Court

901-wp-1731-2002

2. Learned counsel appearing on behalf of

petitioner has submitted that a medical

practitioner cannot fall within the definition

of commercial establishment since a doctor is

providing services to the patients and the

said activity therefore would not fall within

the purview of commercial activity. It is

submitted that prior to 1997 legal

practitioners and medical practitioners were

not included in the said definition of

commercial establishment. However, by virtue

of an amendment in 1997 all these

professionals have been included in the said

definition. It is submitted that the legal

practitioners challenged the validity of the

said amendment by filing a petition.

3. This Court was pleased to hold that the

said amendment is ultra virus and struck down

the inclusion of legal practitioners from the

definition of commercial establishment.

4. It is also submitted that the Apex Court

in 1 “Devendra M. Surti, Dr. vs. State of

Gujarat, also held that private dispensary of

doctor is not commercial establishment. It is

1 AIR 1969 SUPREME COURT 63.

Bombay High Court

901-wp-1731-2002

submitted that the judgment of the Apex Court

therefore, applies to the facts of the present

case.

5. We have heard the learned counsel for the

petitioner and the counsel on behalf of the

State. The Apex Court in “Devendra M. Surti,

Dr. vs. State of Gujarat” (supra) has, after

examining the provisions of the “Gujarat Shops

and Establishments Act”, which are identical

to the provisions of Bombay Shops and

Establishments Act, 1948 come to the

conclusion that “private dispensary of doctor

is not commercial establishment”.

6. In our view, the ratio of the said

judgment squarely applies to the facts of the

present case. Similarly, the Division Bench

of this Court, in “Narendra Keshrichand Fuladi

and Anr. vs.State of Maharashtra, The

Maharashtra Law Journal 1985, page1”

also has

held that “a legal practitioner having a

office cannot be said to carry on commercial

activity and would not fall within the

definition of commercial establishment”. The

ratio of both these judgments squarely applies

to the present case.

Bombay High Court

901-wp-1731-2002

7. In our view, therefore the amendment

incorporating medical practitioners within the

definition of commercial establishment will

have to be held ultra virus and is accordingly

struck down.

8. Criminal prosecution which has been

initiated against the petitioner also,

therefore is, quashed.

9. Petition is accordingly allowed in terms

of prayer clause (a) and (b) and is disposed

of.

(P.D. KODE, J.) (V.M. KANADE, J.

Link to original judjement:

http://bombayhighcourt.nic.in/casequery_action.php

Important Judgement about RTI for Private Hospitals

CENTRAL INFORMATION COMMISSION: New Delhi File No.CIC/SA/A/2014/000004 Appellant : Shri Prabhat Kumar/ Respondent: Directorate of Health Services, GNCTD, Delhi Date of hearing : 03-11-2014; Date of decision : 03-11-2014/7-4-15 Information Commissioner : Prof. M.Sridhar Acharyulu, (Madabhushi Sridhar) Referred Sections: Sections 3, 19(3) of the RTI Act Result : Appeal allowed Disposed of The appellant is present. The Public Authority is represented by Dr. Lily Gangmei, PIO, Directorate of Health Services, GNCTD, Delhi FACTS: 2. The appellant has admitted his father, Late Shri Kailash Prasad Singh on 3.11.2012 having UHID No. FHL6.173745, who died on 3.12.2012 during his hospitalization. According to the appellant the death summary of his father (Annexure)prepared by the team of doctor led by Dr. Vivek Nangia of Fortis Hospital is insufficent, unsatisfactory, ambigious, vague anddoes not have complete facts. Seeking complete Death Summary Report and disclosure ofthe real facts and circumstances leading to death of his father, the appellant has filed RTIapplication on 24.7.2013 seeking information with regard to the same through following 29 points:  1. What are the Registration no.s of Dr Vivek Nangia, Dr Hemant Tiwari, Dr Meenakshi, Dr Ashwani Malhotra and Dr Vishal(All from MICU of Dr Vivek Nangia Team), who were attending to my father Late Shri Kaillash Prasad Singh, since he was admitted in the Fortis Hospital with a complaint of constipation and weakness on 3.11.2012? It is pertinent to mention that the Registration number of all the aforesaid Doctors are not mentioned in any prescription or any piece of paper given by Fortis Hospital. 2. Please provide the name of hospitals, and in what category, for how long and in which department Dr Vivek Nangia, Dr Hemant Tiwari, Dr Meenakshi , Dr Ashwani Malhotra and Dr Vishal were working prior to joining Fortis Hospital, Vasant kunj? 3. Please specify that on what basis it was written in the death summary that my father Late Shri Kailash Singh was a known case of ILD and, if so, since when it was in knowledge of doctors of Fortis, Vasant Kunj? 4. What was the prognosis/diagnosis of doctor at the time of admission, who attended to my father when he was brought to your Hospital on 3.3.2012? 5. Name and registration number of doctor who first attended to my father when he was brought to the Hospital? 6.Please specify as to what was the time when he was brought to the hospital, what was the time when he was first attended to by the doctor and what was the time when he was shifted to the ward?  7. Who took a decision to send my late father for angiography of lungs on 04¬11¬2012? Please provide the registration number of the said doctor? What was the basis of such decision? Please provide documents in support of such decision? 8. Did any doctor physically examine the patient Late Kailash Prasad Singh before sending him for CT Pulmo Angiography. Please provide the copy of the report  of the doctor who examined Late Kailsash Prasad Singh prior to the recommending him for CT Pulmo Angiography. Please also provide the name and the registration number of the doctor who recommended the Late K.P Singh for CT Pulmo Angiography on 04.11.2012. 9.Why it is written in the death summary dated 03.12.2012 that he had recurrent retrosternal chest discomfort? Please provide the document to suggest regarding the aforesaid chest discomfort and medication provided by the hospital for such a chest discomfort. 10. Was the patient late K.P Singh after admission in Fortis Hospital, Vasant Kunj examined for acute Pancreatis or any test conducted to rule out Pancreatis as he was complaining of upper abdominal pain since the day he was admitted. Please provide a copy of the said diagnosis and opinion of the doctor in respect of Pancreatis. 11. Was the patient late Shri KP Singh examined to rule out any kind of tuberculosis. 12.What was the immediate and specific cause of admitting the patient in ICU and putting him on ventilator support for almost 1 month from 05.11.2012 to 03.12.2012? 13.What could be the reason for the so called ‘aspiration’? Was there any examination done to rule out or to ascertain the possibility of aspiration. Please provide the name and registration number of the doctor along with copy of the said report of the examination in respect of the aspiration. 14.Please provide the name and registration number of the Doctor on duty on the night of 04¬ 11-2012 and in the morning of 05¬11¬2012, when an emergency call was given and the Patient Late KP Singh was admitted to MICU. 15.It is written in the death summary that the patient developed a sudden shortness of breath with de¬saturation and went in AF with FVR following a possible aspiration as per history given by the attended who were feeding him? The undersigned being the son of the patient who attending to his father on the very morning of 05.11.2012. the undersigned wants to know what was the exact and specific reason for de saturation of the Patient and going in AF. What investigation was done and what was the outcome of the alleged possible aspiration. As it was not told by the doctor at the point of time? 16.After a few days of his admission to the MICU and putting on ventilator why Late KP Singh was  unable  to  close  his  mouth  and  also  unable  to  move  his  limbs.   Was  there  any controlled force used on his limb and his jaw during his admission in MICU for   the purpose of treatment or stop him to agitate against the ventilator and other devices 17. hat was the cause of “serratia marcescens” infection? How and when this development occur in patient during this month long examination form 03.11.2012 to 03.12.2012? 18. The family members of the patient were told by Dr. Vivek Nangia and his team member that the aforesaid patient had developed “sepsis or septicaemia or septic shock” during the hospitalisation but the same is not specifically mentioned in the death summary. Be that as it may, what was the reason for the development of Sepsis in the patient Late Kailash Prasad Singh during the stay in the Fortis Hospital from 03.11.2012 till he died 03.12.2012? 19.On what date the Tracheostomy done. What was the need of Tracheostomy on the patient late Kailash Prasad Singh and which doctor took a decision to do tracheostomy. Please provide the name and registration number of the sadi doctor? 20.   Was the Tracheostomy done after administering local anaesthesia? Please provide the name of the doctor who administer anaesthesia for the purpose of Tracheostomy done on the patient Late Kailash Prasad Singh. 21.Please provide the name and registration number of the surgeon who conducted surgery of Tracheostomy on the patient Late KP Singh. 22. Why   Late   KP   Singh   never   again   regained   consciousness   after   the   surgery   of Tracheostomy and finally declared dead on 03.12.2012? 23. What was the actual cause of death of Late KP Singh on 03.12.2012? Please provide a documentary proof of cause of death of Late KP Singh. 24.As mentioned in the report that the aforesaid patient was found low haemoglobin and low platelets. Please provide me what was the reason of haemoglobin and platelets coming down suddenly 25. Why, when and at what stage of treatment was the aforesaid patient was Hemodialysed?In total how many times and how many days in continuity the aforesaid patient was Hemodialysed? Please provide the copies of Dialysis prescriptions of Nephrologist or the team of Doctors of Nephrology Department. 26.Please provide the name and registration no of the doctors who prescribed Hemodialysis to be done on the patient Late Sh. K.P Singh. 27. What was the outcome of the Hemodialysis done on the patient? Was such Hemodialysis of   any   benefit   on   the   patient   during   the   Corse   of   his   treatment?   Please   provide documentary evidence of such outcome and benefit. 28. Please provide reasons RDPs, FFPs and loss of VITk in the patient. How many units of platelets were transfused? What was the reason for such a huge requirement of 8.2 units of blood all of a sudden? 29. Who took decision to start living and what was the outcome of this medicine which was started on 30.11.2012 to aforesaid patient?  3.    CPIO replied on 27.8.2013 by enclosing (annexure dt 2.8.2013) a response from the Medical Superintendent, Directorate of Health and Service, GNCTD, who further enclose the copy of reply from the faculty Director of the concern hospital (annexure Dt. 12.8.2013), restated as under: “We wish to inform you that the information asked for is private, confidential and privileged. Please be further advises that the provision of the Right to Information Act do not apply to private hospitals. The provisions of the said act apply only to the Public Authorities/offices. Accordingly we regret that we will not be in a position to provide the requisite information.” 4.   Aggrieved by CPIO reply the appellant made first appeal on 10.9.2013. FAA vide order dated 19.9.2013 held that:   “ CPIO(RTI)DHS(HQ) is directed to forward the application to DMC for answer to question no. 1 as the State Medical Registrar is maintained by DMC. The other queries related to alleged negligence which may be taken up with the appropriate authority i.e., DMC” 5.   For compliance of the FAA order Medical Superintendent , Nursing Home, Directorate of Health Service has wrote a letter to Medical Superintendent , Fortis Hospital, Vasant Kunj That:  “ As the sought information pertains to you, hence, you are requested to provide the same within 3 days on the receipt of this letter positively” 6.     On   non¬compliance   of   the   FAA   order,   the   appellant   made   second   appeal   before commission. Decision:  7.     Both the parties made their submissions.  The appellant contended that his father was admitted into the hospital with the complaint of constipation, but he was kept in the ICU and the hospital conducted unnecessary tests. Appellant had spent nearly Rs.18 lakh on his father’s treatment in the Fortis Hospital, and in spite of that his father expired during the treatment.  The appellant claimed that, being son of patient, who is party to the contract and consumer besides being victim of treatment, he has right to know the details of diagnosis, treatment and the prescriptions of the doctors who have attended him.  When CPIO wrote tothe Hospital seeking the details of treatment given to his father, the Hospital denied.  Hence appellant   was   compelled   to   use   RTI   for   information   from   private   hospital   through the respondent public authority, the regulatory authority of the hospitals.  Appellant complained that the respondent authority has forwarded reply received from the private hospital without taking any regulatory steps to secure the information as per the law.   8.   It is the legitimate right of the son of the deceased patient to know such details of treatment,   which   the   hospital   also   contractually   bound   to   supply,   having   received   a consideration (payment)  from the deceased’s family.  It could not only be breach of contract by the hospital, but also breach of the provisions of Medical Council Act, 1971.  The respondent authority being the regulatory authority, is expected to enforce the law and come to the rescue of the deceased’s family, when the rights are being violated by a private or public hospital.   9.    The issues before the Commission are:  a) Whether information sought by appellant in this case is ‘information’ as per section 2(f)?  b)Whether this Commission has power under RTI Act, to enforce the Right to information of the appellant against a body which is not held to be public authority, by directing the respondent public authority to collect the information by exercising their regulatory power?  c)Whether the Commission has power to consider the authorities of private hospitals as deemed PIOs and proceed against them with penal actions for breach of RTI Act by obstructing the supply of information?  Constitutional Obligation of State Health Regulatory 10.    The preamble to the Constitution of India coupled with the Directive Principles of State Policy strives to provide a welfare State with socialist patterns of society. It enjoins the State to make the “improvement of public health” a primary responsibility. Furthermore, Articles 38, 42, 43 and 47 of the Constitution provide for promotion of health of individuals as well as health care. The Constitution of India also enumerates the separate and shared legislative powers of Parliament and State Legislatures in three separate lists: the Union List, the State List and the Concurrent List. The Parliament and State legislatures share authority over matters on the Concurrent List, which include criminal law and procedure. Health service includes  securing  citizen  from  medical   negligence  by  punishing  concerned  for   crime  of medical negligence and compensating the damage caused by doctor or hospital through negligence under tort action or securing the enforcement of contractual obligation under law of contract. Consumer Protection Act is another legislation which is aimed at preventing negligence   and   deficient   services   besides   assuring   right   to   information   about   medical treatment given to the patient at the threat of imposing compensation.  11.    The Working Group on Clinical Establishments, Professional Services Regulation and Accreditation of Health Care Infrastructure, constituted by the Planning Commission for the 11th  Five¬Year  Plan,  pointed  out  in  its  report   that   although  the  "for¬profit  private  sector accounts for...50% of inpatient care and 60  &0% of outpatient care...IT has...remained largely fragmented and uncontrolled", with problems ranging from "inadequate and inappropriate treatments, excessive use of higher technologies, and wasting of scarce resources, to serious problems  of   medical   malpractice  and  negligence"  (Government  of   India.   Report   of  The Working   Group   on   Clinical   Establishments:   Professional   Services   Regulation   and Accreditation of Health Care Infrastructure. New Delhi: Planning Commission; 2006, p.6.) 12.       There exists legislation with respect to licensing of medical professionals such as doctors, nurses, dentists and pharmacists with a view to control their entry into the market. Statutory regulatory councils have been established to monitor the standards of medical education, promote medical training and research activities, and oversee the qualifications, registration,   and   professional   conduct   of   doctors,   dentists,   nurses,   pharmacists,   and practitioners of other systems of Medicine such as Ayurveda, Yoga, Unani, Siddha and Homeopathy. Important of these laws are: the Indian Medical Council Act, 1956, the Indian Nursing Council Act, 1947; the Indian Medicine Central Council Act, 1970; the Homeopathy Central Council Act, 1973; and the Pharmacy Act, 1948. Almost all of these laws establish councils that set forth uniform educational and qualification standards. In addition, each statute establishes a central registry for individuals certified to practice the field of medicine regulated. Finally, councils often prescribe standards of professional conduct and determine which actions amount to professional misconduct.  13.       As ‘ health’ is a state subject, some State legislation had been brought out by UTs/States quite early such as:  i. The Bombay Nursing Homes Registration Act, 1949; ii. Delhi Nursing Homes Registration Act, 1953; iii. Tamilnadu Private Clinical Establishments Act, 1997.  The High Courts of Delhi and Mumbai have also intervened through their various orders for effective implementation of these statutes.  For the empanelment of hospitals and diagnostic centres by the Central Government health Scheme, it has now been made mandatory that all diagnostic   labs   must   be   certified   by   the   National   Accreditation   Board   for   Testing   and Calibration Laboratories (NABL). Similarly, physical inspections of hospital that have applied for empanelment have been entrusted by Ministry of Health and Family Welfare to the Quality Council of India. 14.    The Planning Commission of India recognized in its Report on the Working Group on Clinical Establishments, Professional Services Regulation and Accreditation of Health Care Infrastructure for 11th Five Year Plan in 2006, the need for a central legislation for registration of  clinical  establishments  in  the country.  The Working group suggested  draft  legislation prepared by Ministry of Health and Family Welfare should be carried forward. But till now there is no effective regulation and if the private hospital refuses to give medical record, the patient is left with no effective remedy even today. 15.       Professor Kalpana Kannabiran, in her article in Indian Journal on Clinical Ethics, Volume 5, No. 3, 2008, while reviewing the Clinical Establishment (Registration & Regulation) Bill,  2007  stated:    “In  a situation  of  complete lack  of  accountability,  any  move towards regulation  and  monitoring  is  welcome.   While  generally  concerns  have  been  raised  with respect to the impossibility of monitoring rural health care and unscrupulous practices at the lower end, what is equally necessary to address is the lack of accountability in corporate health care and unregulated practices at the upper end of the cost ladder. Between these twopoints lie a host of variations in health care delivery that are unregulated and for the most partuncharted. There is also the encouraging reality of community health care initiatives across the country that have done remarkable work under extremely difficult conditions, developing priorities, standards and measures, and demonstrating results with complete transparency and accountability”. (http://ijme.in/index.php/ijme/rt/printerFriendly/509/1330) ‘Information’ under section 2(f) 16.     This Commission has examined the issue of right of patient to have the medical recordsin Nisha Priya Bhatia v Institute of Human Behaviour and Allied Sciences GNCTD, FileNo.CIC/AD/A/2013/001681SA, decided 23 July 2014) and stated “the Patient has a right tohis/her medical record and Respondent Hospital Authorities have a duty to provide the sameunder Right to Information Act, 2005, Consumer Protection Act, 1986, The Medical CouncilAct as per world medical ethics. The Commission recommended the Public Authority todevelop a timeframe mechanism of disclosure of medical records to patients or their relativeswith safeguards for privacy and confidentiality of the patient”. In that order Commissionreferred to various legislations. “We need to refer to provisions of Consumer Protection Act,1986 to ascertain whether appellant has the right to information about her own medical record.  Right to information under RTI and Consumer Protection Act: 17.   Expression “Consumer’’ is defined in the Consumer Protection Act, 1986:     S 2(1) (d) "consumer" means any person who, ¬(i) OMITTED (ii) hires (or avails of) any services for a consideration which has been paid or promised or partly paid and partly promised, or under any system of deferredpayment and includes any beneficiary of such services other than the person who hires (or avails of) the service for consideration paid or promised, or partly paid and   partly   promised,   or   under   any   system   of   deferred   payment,   when   such services are availed of with the approval of the first mentioned person,    Similarly as per Section 2(1)(o) : "service" means –  “ service of any description which is made available to the potential users and includes the provision of facilities in connection with banking, financing, insurance, transport, processing, supply of electrical or other energy, board or lodging or both, (housing construction), entertainment, amusement or the purveying of news or other information, but does not include rendering of any service free of charge or under a contract of personal service.” 18.  In a landmark judgment in Indian Medical Association Vs. V.P Shantha (1995(6) SCALE 273) Hon’ble Supreme Court of India has stated that “Service” rendered by Medical  Practitioner  were  covered  under   Consumer  Protection  Act.  Hon’ble  Supreme Court laid down: (1) Service rendered to a patient by a medical practitioner (except where the doctor renders service free of charge to every patient or under a contract of personal service), by way of consultation, diagnosis and treatment, both medicinal and surgical, would fall within the ambit of 'service' as defined in Section 2(1)(o) of the Act.  …… (10) Service rendered   at   a   Government   hospital/health   center/dispensary where services are rendered on payment of charges and also rendered free of charge to other persons availing such services would fall within the ambit of the expression 'service' as defined in Section2(1)(o)of theAct irrespective of the fact that the service is rendered free of charge to persons who do not pay for such service. Free service would also be "service" and the recipient a "consumer" under the Act.  (11) Service rendered   by   a medical practitioner   or   hospital/nursing   home cannot be regarded as service rendered free of charge, if the person availing the service has taken an insurance policy for medical care where under the charges for consultation, diagnosis and medical treatment are borne by the insurance company and such service would fall within the ambit of 'service' as defined in Section 2(1)(o) of the Act. (12)  Similarly, where, as a part of the conditions of service, the employer bears the expenses of medical treatment of an employee and his family members dependent on him, the service rendered to such an employee and his family members by a medical practitioner or a hospital/nursing home would not be free of charge and would constitute 'service' under Section 2(1)(o) of the Act.” 19.   Thus, the appellant is a consumer in his capacity as ‘patient’ as per the definition of Consumer under Consumer Protection Act 1986 and according to Supreme Court’s landmark judgment in IMA v. Shantha, the medical services are ‘services’ under that Act.  Indian Medical Council Act  20.     The  Medical   Council   of   India  has  imposed  an  obligation  on  Hospitals  as  per   the regulations notified on 11th  March 2002, amended up to December 2010 to maintain the medical record and provide patient access to it. These regulations were made in exercise of the powers conferred under section 20A read with section 33(m) of the Indian Medical Council Act, 1956 (102 of 1956), by the Medical Council of India, with the previous approval of the   Central   Government,   relating   to   the   Professional   Conduct,   Etiquette   and   Ethics   for registered medical practitioners, namely:¬ Maintenance of Medical Records:  1.3.1.  Every  physician  shall  maintain  the medical  records pertaining to his/her indoor patients for a period of three years from the date of commencement of the treatment in a standard pro¬forma laid down by the Medical Council of India and attached as Appendix 3.  1.3.2. If any request is made for medical records either by the patients/authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours. With the enforcement of the MCI Regulations, 2002 it is made clear that the patient has a right to claim medical records pertaining to his treatment and the hospitals are under obligation to maintain them and provide them to the patient on request. 21.   Hon’ble Kerala High Court recognizing the above principle in  Rajappan Vs. Sree Chitra Tirunal Institute for Medical Science and Technology (ILR 2004 (2) Kerala 150).  In this case the Petitioner was the father of an epilepsy patient who died in the course of treatment in the Respondent Medical Institution, which was a statutory corporation created by the Government of Kerala. After her death, the Petitioner applied   for   medical   records   pertaining   to   the   treatment   of   his   daughter.   The husband of  the deceased was given case summary  and discharge record and investigation report. The request of the Petitioner for copies of medical records was   declined.   Therefore   he   approached   this   Court   under   Article   226   of   the Constitution   for   necessary   direction.   Allowing   the   petition,   the   High   Court extracted relevant regulations of Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 as under:  Maintenance of Medical Records: 1.3.1.   Every   physician   shall   maintain   the   medical   records   pertaining   to his/her   indoor   patients   for   a   period   of   three   years   from   the   date   of commencement of the treatment in a standard proforma laid down by the Medical Council of India and attached as Appendix 3. 1.3.2.   If   any   request   is   made   for   medical   records   either   by   the patients/authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours. “…..Appendix 3 (of Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002) referred to in regulations 1.3.1 provides for information, among other things, pertaining to diagnosis, investigations advised with reports, diagnosis after investigation, and advice. Therefore it is obvious from the appendix that what is to be given is the full details about the patient, namely, the findings pertaining to the deceased. That is the diagnosis and the periodical advice for treatment. As and when diagnosis is made the treatment will be advised by the doctor to the nursing staff in the case sheet itself. Therefore the case sheet will show the progressive testing, diagnosis and treatment given to the patient. The details to be furnished in Appendix 3 are of comprehensive in nature and should contain the diagnosis and treatment given to the patient during the period, the patient was under treatment. Regulation 1.3.1 has to be read with regulation 1.3.2 which makes it mandatory that any patient requesting for medical records should be furnished copies of "documents" within 72 hours from the   date   of   demand.   In   other   words,   the   patient's   right   to   receive documents   pertaining   to   his/her   treatment   is   recognised   by   the Regulations.   The   documents   referred   to  in  Regulation   1.3.2  necessarily have to be the entire case sheet maintained in the hospital which contains the result of diagnosis and treatment administered, the summary of which is   provided   in   Appendix   3.   Therefore   the   petitioner   is   entitled   to photocopies of the entire case sheet and the respondents cannot decline to give   the   same   by   stating   that   the   details   are   available   in   Appendix   3 furnished, which they are willing to furnish.” Kerala High Court in the above case observed that: It is also to be noticed that Regulations do not provide any immunity for any medical record to be retained by any medical practitioner of the hospital from being given to the patient. On the other hand it is expressly provided that a patient should be given medical records in Appendix 3 with supporting documents. Therefore in the absence of any immunity either under the Regulations or under any other law, the respondent¬Hospital is bound to give photocopies of the entire documents of the patient.  Standing counsel for the respondent Hospital submitted that the documents once furnished will be used as evidence against   the   hospital   and   against   the   doctors   concerned.   I   do   not   think   this apprehension will justify for claiming immunity against furnishing the documents. If proper service was rendered in the course of treatment, I see no reason why   the   hospital,   or   staff,   or   doctors   should   be   apprehensive   of   any litigation. A patient or victim's relative is entitled to know whether proper medical care was rendered to the patient entrusted with the hospital, which will be revealed from case sheet and medical records. There should be absolute   transparency   with   regard   to   the   treatment   of   a   patient   and   a patient or victim's relative is entitled to get copies of medical records. This is recognized by the Medical Council Regulations and therefore petitioner is entitled to have copies of the entire medical records of his daughter which should be furnished in full.  Case Law about Right of information of Patients:  22.         There  are  several   decisions  by  the  High  Courts  and   Consumer   Commissions establishing the right of patient to information and duty of the Hospitals to provide the same. In Kanaiyalal Ramanlal Trivedi v Dr. Satyanarayan Vishwakarma 1996; 3 CPR 24 (Guj); I (1997) CPJ 332 (Guj); 1998 CCJ 690 (Guj), the hospital and doctor were held guilty of deficiency in service as case records were not produced before the court to refute the allegation of a lack of standard care. 23.          Thus, if hospital takes up a plea of record destroyed, it was held that it could be a case   of   negligence.   In  S.A.Quereshi   v   Padode   memorial   Hospital   and   ResearchCentre II 2000. CPJ 463 (Bhopal) it was held that the plea of destroying the case sheet asper the general practice of the hospitals appeared to the court as an attempt to suppresscertain facts that are likely to be revealed from the case sheet. The opposite party was found negligent as he should have retained the case records until the disposal of the complaint. 24.         Explaining the consequences of denial of medical record, it was held that an adverse inference could be drawn from that. In case of Dr. Shyam Kumar v Rameshbhai, Harmanbhai Kachiya 2002;1 CPR 320, I (2006) CPJ 16 (NC). The National Commission said  that   not   producing  medical   records  to  the  patient   prevents  the  complainant   from seeking an expert opinion and it is the duty of the person in possession of the medical records to produce it in the court and adverse inference could be drawn for not producing the records.  25.           In  Raghunath Raheja v Maharashtra Medical Council, AIR 1996 Bom 198, Bombay High Court upheld the right of patient to medical record very emphatically. Judges M. Shah and A. Savanth stated:  “We are of the view that when a patient or his near relative demands from the Hospital or the doctor the copies of the case papers, it is necessary for the Hospital authorities and the doctors concerned to furnish copies of such case papers to the patient or his near relative. In our view, it would be necessary for the Medical Council to ensure that necessary directions are given to all the Hospitals and the doctors calling upon then to furnish the copies of the case papers and all the relevant documents pertaining to the patient concerned. The hospitals and the doctors may be justified, in demanding necessary charges for supplying the copies of such documents to the patient or the near relative. We, therefore, direct the first respondent Maharashtra Medical Council to issue necessary circulars in this behalf to all the hospitals and doctors in the State of Maharashtra. We do not think that thet hospitals or the doctors can claim any secrecy! or any confidentiality in the matter of copies of the case papers relating to the patient. These must be made available to him on demand, subject to payment of usual charges. If necessary, the Medical Council may issue a press¬note in this behalf giving it wide publicity in all the media. ” There   are   several   decisions   by   High   Courts   and   Consumer   Dispute   Redressal Commissions which emphasized the right to medical records from hospitals or doctors whether they are private or public, running for profit or charitable.  Some more decisions of National Commission:  1. The hospital was held vicariously liable for the negligent action of the doctor on the basis of the bill showing the professional fees of the doctor and the discharge certificate under the letterhead of the hospital signed by the doctor (P.P. Ismail v K.K. Radha 1997 (2) CPR 171 (NC); I(1998) CPJ 16 (NC); (1997) 5 CTJ 685 (CP) (NCRDC); 1999 CPJ 99 (NC)). 2. It was held that the hospital was guilty of negligence on the ground that the name of the anesthetist was not mentioned in the operation notes though anesthesia was administered by two anesthetists. There were two progress cards about the same patient on two separate papers that were produced in court (Meenakshi Mission Hospital and Research Centre v. Samuraj and Anr., I(2005) CPJ 33 (NC)). Some more decisions of State Commission:  1. Decision of Chandigarh Commission: It is negligence on the basis of the records, which seemed to be manipulated (Nihal Kaur v. Director, PGI, Chandigarh. 1996 (3) CPJ 112 (Chandigarh (U.T.) CDRC.). 2. Decision of AP State Commission:  Negligence was established as the case sheet did not contain  a   proper   history,   history   of   prior   treatment   and  investigations,   and   even  the consent papers were missing.  (Force v. M Ganeswara Rao . 1998 (3) CPR 251; 1998 (1) CPJ 413 (AP SCDRC) ).  3. Decision of Kerala State Commission: The failure to deliver X¬ray films is held to be deficient service. The patient and his attendants were deprived of their right to be informed of the nature of injury sustained (V P Shanta v. Cosmopolitan Hospitals (P) Ltd 1997 (1) CPR 377 (Kerala SCDRC.). 4. Decision of Gujarath State Commission: The evidence of the surgeon cannot be believed because   only   photocopies   were   produced   to   substantiate   the   evidence   without   any plausible explanation regarding the absence of the original (Devendra Kantilal Nayak v Dr. Kalyaniben Dhruv Shah 1996 (3) CPR 56; I (1997) CPJ 103; 1998 CCJ 544 (Guj)). 26.     Under Section 2(f) of the RTI Act, which defined ‘information’, imposes an obligation on the Commission to enforce the right to information available to the appellant under any other law. This Commission observes that both the laws¬ RTI Act and CPA Act provided the appellant a strong and undeniable right to information of her own medical record.  Law Secretary’s letter to Health Secretary 27.     Referring to this order of CIC, Union Law Secretary P.K. Malhotra has, in a letter to Union Health Secretary Lov Verma, said that according to the CIC’s July 23 order, a patient has a right to his/her medical record which is rooted in Article 19 and 21 of the Constitution and the hospital authorities have a duty to provide the same under Right To Information Act, Consumer Protection Act, Medical Council Act and world medical ethics dealt with constitutional rights. Mr Malhotra wrote, “If there are existing instructions to this effect, the same need to be reiterated and the concerned authorities sensitised about the same, and if there are no existing instructions, the health ministry may consider issuing suitable orders or rules so that patients get copies of their medical record, including details of treatment, as a matter of right.”  The law ministry has stated that “most of the time the hospital authorities do not provide details of the medical record or the treatment given to a patient.” The letter quoted this CIC’s order saying patients have a right to their medical records which is rooted in Articles 19 and 21 of the Constitution and respondent hospitals have a duty to provide it. (August 22, 2014) Appellant’s Right to information  28.     Besides the above, the appellant and his father are the parties to the contract with the concerned hospital who agreed to render service on payment of consideration. Nonfurnishing of medical records amounts to deficiency in service under Consumer Protection Act, and also breach of contract, for which the appellant is entitled to remedy of payment of compensation.  29.   In Poorna Prajna Public School vs Central Information Commission & another decided on 25 September, 2009 by Delhi High Court in Writ Petition  (CIVIL) NO. 7265 OF 2007, Justice Sanjeev Khanna explained the objective of RTI Act: “ RTI Act was enacted in the year 2005 as a progressive and enabling legislation with the object of assigning meaningful role and providing access to the citizens. It ensures openness and transparency consistent with the concept of participatory democracy and constitutional right to seek information and be informed. It also ensures that the Government and their instrumentalities are accountable to the governed and checks corruption, harassment and red¬-tapism”.  Section 2(f). says:  information  means   any   material   in   any   form,   including   records,   documents, memos, e¬mails, opinions, advices, press releases, circulars, orders, logbooks, contracts, reports, papers, samples, models, data material held in any electronic form and information relating to any private body which can be accessed by a public authority  under  any  other  law  for the time being in force.  (emphasis supplied) The second part of the definition expands the scope of the law and extends to cover   private   bodies   also.   First   part   deals   with   information   ‘held’   by   public authorities and second part deals with information held by private bodies but under control of public authorities, if provided by other law.  Section 2(j) says:  ‘right to information’ means the right to information accessible under this Act which is held by or under the control of any public authority and includes the right to (i) inspection of work, documents, records;   (ii)        taking notes, extracts, or certified copies  of   documents  or   records;   (iii)   taking  certified  samples  of   material;   (iv) obtaining information in the form of diskettes, floppies, tapes, video cassettes or in any other electronic mode or through printouts where such information is stored in a computer or in any other device;  30.   Justice Sanjay Khanna in above case, dealt with the harmonious reading of two sections: Information as defined in Section 2(f) means details or material available with the public authority. The later portion of Section 2(f) expands the definition to include details or material which can be accessed under any other law from others. The two definitions have to be read harmoniously. The term   ‘ ― held by or under the control of any public authority’ in Section 2(j) of the RTI Act has to be read in a manner that it effectuates and is in harmony with the definition of the term ― ‘information’ as defined in Section 2(f).  Justice Sanjay Khanna rightly said:  The said expression used in Section 2(j) of the RTI Act should not be read in a manner that it negates or nullifies definition of the term   ‘information’ in Section ― 2(f) of the RTI Act. It is well settled that an interpretation which renders another provision or part thereof redundant or superfluous should be avoided. Information as defined in Section 2(f) of the RTI Act includes in its ambit, the information relating to any private body which can be accessed by public authority under any law for the time being in force. Therefore, if a public authority has a right and is entitled to access information from a private body, under any other law, it is ― ‘information’ as defined in Section 2(f) of the RTI Act.   The term  held by the or ― under the control of the public authority  used in Section 2(j) of the RTI Act will include information which the public authority is entitled to access under any other law from a private body. A private body need not be a public authority and the said term  private body ―   has been used to distinguish and in contradistinction to the term  ‘public authority’ as defined in Section 2(h) of the RTI Act. Thus, information which a ‘public authority’ is entitled to access, under any law, from private body, is ‘information’ as defined under Section 2(f) of the RTI Act and has to be furnished. 31.  To further clarify, Justice Sanjay Khanna reiterated:  “Therefore, section 2(f) of the RTI Act requires examination of the relevant statute or law, as broadly understood, under which a public authority can access information from a private body. If law or statute permits and allows the public authority to access the information relating to a private body, it will fall within the four corners of Section 2(f) of the RTI Act”.  32.  The Commission examined the Medical Council Act, 1971 which gave the appellant right to information and Consumer Protection Act, 1986 which imposed an obligation on service providers to inform. Both the laws emphasized that the appellant has the right to medical   records   as   explained   above  which   the   Fortis   Hospitals   cannot   avoid   simply because it is a private body and not public authority as per Section 2(h) of RTI Act.  33.  Justice Sanjay Khanna explained that as the information is accessible through other law, conditions prescribed there should be satisfied. He said: “If there are requirements in the nature of preconditions and restrictions to be satisfied by the public authority before information can be accessed and asked to be furnished from a private body, then such preconditions and restrictions have to be satisfied. A public authority cannot act contrary to the law/statute and direct a private body to furnish information. Accordingly, if there is a bar, prohibition, restriction or precondition under any statute for directing a private body to furnish information, the said bar, prohibition, restriction or precondition will continue to apply and only when the conditions are satisfied, the public authority is obliged to get information. Entitlement of the public authority to ask for information from a private body is required to be satisfied”. 34.  Under Consumer Protection Act, 1986 the condition that need to be satisfied before seeking information is that he must be a consumer, who paid for the medical service or fee prescribed. It is not the case of Fortis Hospital that patient or his son  (appellant) not paid the fee or that he was not consumer or that the hospital did not render the services. Hence the appellant has satisfied all conditions prescribed under Consumer Protection Act, 1986 which entitles him to ‘information’ held by private authority as controlled by the public authority, i.e., respondents in this case.  Looking from the other law, Medical Council Act 1971, the patient fulfilled conditions of being a patient and paying a fee. Thus under two enactments, the patient’s (appellant’s) right to information is established along with the obligation of public authority to demand the information exercising their regulatory powers and the obligation of the Fortis Hospital to provide medical records to the appellant.  35.  Justice Sanjay Khanna referred to the opportunities available to private authority to raise objections for disclosure of information as sought by the applicants. Justice Khanna says as third party could rise defences, exceptions and exemptions under RTI Act, private body also could do. Third party as per Section 2(n) means a person other than the citizen making a request for information and includes a public authority.   Thus the term ‘third party’ includes not only the public authority but also any private body or person other than the citizen making request for the information. Like third party, private body also can appeal under Section 19(4). A private body or third party can take objections under Section 8 of the RTI Act before the public information officer or the CIC.   In terms of Section 11(4) of the RTI Act, an order under Section 11(3) rejecting objections of the third party is appealable under Section 19 of the RTI Act before the CIC. 36.     Thus it is established that the medical records of the father of appellant held by Fortis Hospital which treated him, is held to be ‘information’ under last part of section 2(f) as the Medical Council Act, 1971 provided that right, as referred above in Paras 13 and 14. Then   the   question   is   whether   the   respondent   public   authority   Directorate   of   Health Services Delhi is entitled to have access to medical records of patients?  The Directorate in   its   website   (http://www.delhi.gov.in/ wps/wcm/connect/doit_health/Health/Home/Directorate+of+Health+Services/)claimed:   “In Delhi, health care facilities are being provided by both Government & Non¬Government Organizations.   Among   the   Government   Organizations,   Directorate   of   Health   Services (DHS)  of Government NCT of Delhi is the major agency related to health care delivery….. This Directorate not only actively participates in delivery of health care facilities but also coordinates   with   other   Govt.   and   Non   Government   Organizations   for   health   related activities   for   the   improvement   of   health   of   citizens   of   Delhi.   DHS   is   instrumental   in coordination and implementation of various  national and state health programmes.  This Directorate also monitors the health services being provided by registered Private Nursing Homes. The registration is done subject to the fulfillment of pre requisite of Delhi Nursing Homes Registration ACT and renewal in yearly basis. The registration of Private Nursing Homes and hospitals is mandatory under this Act.” 37.    Under Clinical Establishments (Registration & Regulation) Act 2011, Section 12 (1) says for registration and continuation, the clinical establishments shall fulfill the conditions, among others, (i) the minimum standards of facilities and services as may be prescribed, CIC/SA/A/2014/000004 Page 22 (iii) provision of maintenance of records and reporting as may be prescribed.   Under section 42, the clinical establishment is liable to be penalized with penalty up to Rs 5 lakh for disobedience of director or order lawfully given by any person or authority.  38.   The Regulatory has even the power to cancel the registration if the conditions for registration are not fulfilled. Under both the laws, Delhi Nursing Homes Registration Act, Clinical Establishments (Registration & Regulation) Act 2011, the respondent authority has a duty to coordinate and facilitate the health services. Securing medical record of the patient is the service and not providing the same is deficiency under Consumer Protection Act as held by different courts, referred above. Thus the respondent public authority is entitled to access the information held by Fortis Hospital which means the information sought is under its control.  39.   The Fortis Hospital has raised objection to disclose information saying that it was ‘private, confidential and privileged’.   None was present on behalf of Fortis Hospital. Representative of Public Authority did not take any defence or raised any objection under any exception. The Commission rules out this objection of Fortis Hospital as information was a) not private, because the information about treatment given to patient on payment of fee belong to patient or his heirs and it can never be the ‘private’ information of hospital and thus it will not fall under exemption 8(1)(j) as it has relationship with public activity which   includes   treating   any   patient,   which   is   the   purpose   of   the   establishment   of commercial private hospital as that of Fortis Hospital, b) not confidential because patient is not asking any information which has any commercial value for the hospital, he is asking because   he   suspects   negligence   in   treatment   and   lack   of   necessity   in   conducting diagnostic tests, it will not fall under category of protected commercial confidence or competitive information as provided under section 8(d), and c) not privileged at all which does not attract any provision of RTI Act or Consumer Protection Act, or Medical Council Act. Using three words without any further explanation or basis by Fortis Hospital to deny the right of patient and his son reflects arrogance and recklessness of hospital and fortifies the   common   impression   of   the   patients   that   they   are   unethically   being   fleeced   by commercially greedy hospital shops. Fortis Hospital’s denial shows disrespect to three enactments referred above, their professional duty and contractual obligation towards the patient from whom they have collected huge amount of money. They should have shown professional character and dignity by furnishing the required medical records if they really had not committed any greedy exploitation of this patient. They lost a chance to establish their integrity, if any. It is equally unethical and immoral on their part in declining to give information, reasons for treatment, or failure of treatment, if any or entire medical record besides coming up with baseless and unreasonable grounds.  40.     Thus the claim of the hospital that the information is private, confidential and privileged, is untenable and illegal and by this they have violated the right to information of the appellant based on grounds which were not part of exceptions under Section 8 of RTI Act,   for   which   the   appellant   has   all   remedies   under   breach   of   contract,   Consumer Protection Act, Medical Council Act besides RTI Act. And if the disclosed medical record reveals gross negligence, the patient’s son (appellant) may also have recourse to criminal proceedings under IPC.  41.  The Commission, therefore, holds that undoubtedly the appellant, being a patient has specific right to detailed medical record about treatment under Section 3 of the RTI Act and also under Consumer Protection Act, 1986”.   Hence, the information sought by the appellant is the ‘information’ as per Section 2(f) of RTI Act.  Commission’s authority to implement RTI of appellant 42.    Once the information sought by appellant is ‘information’ under s 2(f) of RTI Act, entire law will come to the rescue of the right of appellant and the Commission has statutory duty to enforce his right with all its powers available under RTI Act to secure the information legitimately sought by the appellant.  43.         In   the   case   of  Jarnail   Singh   vs.   Registrar,   Cooperative   Societies   Delhi (Complaint   No.CIC/WB/C/2006/00302,   dated   9/4/2007),   the   CIC   ordered   the   private authority to provide inspection under the supervision of the public authority. In this case the applicant had sought some information from the Registrar, Cooperative Societies (RCS)   regarding   the   alleged   irregularities   in   the   allotment   of   a   house   to   him   by   a cooperative group housing society. However, the information pertaining to these issues was available with the management of the cooperative society, which could not be treated as a public authority in terms of the definition of public authority under the RTI Act. The Commission held that a cooperative society is not a public authority, but because the information sought by the applicant/appellant is available to the Registrar under the Delhi Cooperative  Societies  Act,  such  information  can  be  provided  to  the  applicant,  under Sections 2(f) and 2(g) of the RTI Act. It was also ordered by the Commission that the applicant   will   be   provided   the   required   information   from   the   office   records   of   the cooperative society under the supervision of a competent officer of the RCS. 44.    Since the CPIO of respondent authority sought to collect the information asked by the appellant, the Fortis Hospital should have performed   their legal responsibility of furnishing   information.   But   by   denial   of   information   through   baseless   grounds   the authorities of Fortis Hospital created hurdles and caused breach of the provisions RTI Act, necessitating the Commission to initiate penal proceedings against them under Section 20 of RTI Act. It is relevant to see Section 5(4) and (5).  Section 5(4) of the RTI Act, 2004 The Central Public Information Officer or State Public Information Officer, as the case may be, may seek the assistance of any other officer as he or she considers it necessary for the proper discharge of his or her duties. Section 5(5) of the RTI Act, 2004: Any other officer, whose assistance has been sought under sun section (4) shall render all assistance to the Central Public Information Officer or State Public Information Officer, as the case may be, seeking his or her assistance and for the purposes of any contravention of the provision of this Act, Such other officer shall be treated as a Central Public Information Officer or State Public Information Officer, as the case may be. 45.     Under Section 5(4) CPIO can seek assistance of any other officer as he or she considers it necessary for the proper discharge of his or her duties. The Commission finds that by writing a letter to Fortis Hospital to give information, respondent authority sought assistance of the authorities in Fortis Hospital. By that act the authority has initiated action under RTI Act, 2005. As they resorted to Section 5(4), next sub¬clause Section 5(5) will necessarily follow, which says that CPIO shall treat such officer whose assistance is sought, as CPIO.  46.    The Commission observes that under section 2(f) of the RTI Act, it is the duty of the Public Authority who is vested with the regulatory powers over all the Hospitals, including the Private Hospitals such as Fortis in Delhi, to see that the right as enshrined in the Medical Council Act, 1971, and other relevant Acts,  is obeyed by the said hospitals.  This law and the RTI Act   mandates   that every hospital whether it is private or public, to provide the  medical  record within  72  hours  of  the death of  the  patient.    Hence the Commission has authority to implement RTI of the appellant.  47. The Commission is not going into the question, whether Fortis Hospital is a public authority or not. Every person has a right to seek the information, define under section 2(f) of the Act. That right of the appellant has been violated by the Respondent authority and Fortis Hospital who refused by stating that the information was confidential and privileged. Considering it as a serious case of shading the truth in dark, the commission is exercising the powers under section 18 of the RTI Act, text of which is reproduced as under: Section 18 of RTI Act says:  (1) Subject to provisions of this Act, it shall be the duty of the Central Information Commission or State Information Commission, as the case may be, receive and inquire into a complaint from any person, ….(b) who has been refused access to any information requested under this Act.  (2): Where the CIC or SIC as the case may be, shall, is satisfied that there are reasonable grounds to inquire into the matter, it may initiate inquiry in respect thereof.  (3) The Central Information Commission or SIC, as the case may be, shall, while inquiring into any matter under this section, have the same powers as are vested in a civil Court while trying a suit under the Code of Civil Procedure 1908, in respect of the following matters, namely… (a) summoning and enforcing the attendance of persons and compel them to give oral or written evidence on oath and to produce the documents or things; (b) requiring the discovery and inspection of documents; (c) receiving evidence on affidavit;  (d) requisitioning any public record or copies thereof from any court or office; (e) issuing summons for examination of witnesses or documents; and (f) any other matter which may be prescribed. (4): Notwithstanding anything inconsistent contained in any other Act of Parliament or State Legislature, as the case may be, the Central Information Commission or State Information Commission, as the case may be, may, during inquiry of any complaint under this Act, examine any record to which this Act applies which is under the control of the public authority, and no such record may be withheld from it on any grounds.  48.  The above provisions show that the Commission has enough power to summon and enforce attendance of any persons, compel them to give oral or written evidence on oath and produce the documents or things and ultimately impose the penalty as prescribed under Section 20 of RTI Act.   49.  The appellant who filed this second appeal, during hearing complained against the respondent authority for not securing the information from Fortis Hospital, exercising their regulatory power over that hospital, and against the authorities of the Fortis Hospital who made an illegal claim that information sought was private, confidential and privileged, which   amount   to   refusal   of   access   to   information   requested   under   RTI   Act,   which empowers the CIC to implement such right.  50.    This second appeal and complaint deals with the right to life of father of the appellant as declared under Article 21, which include right to quality treatment and other medical services  without   deficiency   and  negligence   in  proportion  to  the  high  cost   they  were charged to pay. The Commission finds that the respondent public authority and the Fortis Hospital have denied the appellant of his right to legally agitate against violated right to life of his father, which include the right to medical records.  51.    The Commission also holds that even if the Fortis Hospital is a private body it is not immune from statutory duty of providing medical record to the patient or his son. Private body cannot claim a right to take the life of a patient by negligence and when especially it was suspected of medical negligence, it cannot deny the medical records. In fact, the Commission has every reason to draw an adverse inference against the hospital, from this unreasonable, unethical, illegal and unconstitutional denial of information that it is trying to hide something which might establish medical negligence if disclosed. It is in the interest of justice, establishment of truth, and of course, reputation or credibility, if the private hospital has and is interested in protecting it, it has to give the medical record on its own. The Commission is surprised at the defiant attitude of Fortis Hospital in denial of medical record and indifferent attitude of public authority, the respondents in not securing it.  52.   The Commission recommends the Union Government and Delhi Government to take this as undesirable example of defiance of private hospitals and of their indifference towards lives, health and rights of the patients from who they fleece huge amounts of money, to come up with a strict mechanism of enforcing the rights of the patients as per law.   The   Commission   also   recommends   the   Governments   to  take   note   that   right   to information of medical records of patient is equal against both public and private hospitals and any attempt to ignore enforcement of this right against private hospital will amount to practice of discrimination in violation of Article 14 of the Constitution.  53.   The Commission directs officer¬in¬charge of administration of the Fortis Hospital or any other responsible person having authority and knowledge about the case of the father of the appellant to furnish: a. the certified copies of entire medical record including a note explaining the cause of death of the father of the appellant,  b. the certified copies of documents based on which the causes were ascertained,  c. the certified copies of bills and receipts of payments made by or for the father of the appellant within 21 days from the date of receipt of this order, free of cost to the appellant.  The  Commission   also   issues  a  show  cause  notice  to  the   officer¬ in¬charge  of administration   of   the   Fortis   Hospital   or   any   other   responsible   person   having authority and knowledge to explain why maximum penalty cannot be imposed against him for breach of right to information of appellant within 21 days from the date of receipt of this order.  54.   The Commission issues a show cause notice to CPIO of respondent authority why maximum penalty cannot be imposed against him for not exercising regulatory power to secure information of medical treatment to appellant within 15 days from the receipt of this order.   55.    The Commission also directs the respondent authority to compel the said private hospital with its regulatory power provided under the law to comply with the provisions of the Nursing Homes Registration Act or Clinical Establishment (Registration & Regulation) Act, MCI Act and RTI Act or any other rule or provision under any law, and provide the entire information to the appellant within one 21 days from the date of receipt of this order.  56.    The Commission recommends the Government of India, states and Union Territories, besides the respondent authority in this case, to take necessary steps to enforce the right to information, i.e., forcing the private hospitals to give medical records of the patients on day to day basis, because this daily disclosure will prevent undesirable practices of altering records after damage caused to patient. Forcing the private hospitals to provide daily-wise medical records will also act as a check on some hospitals from resorting to extortionist, inhuman and ruthless business of prescribing unnecessary diagnostic tests, unnecessary   surgical   operations,   caesarean   deliveries,   unwarranted   angioplasties, inserting stents, without need, or of substandard nature, or putting low quality stent while collecting price of high quality stent, and several such malpractices amounting to medical terrorism, etc. They should not be allowed to such malpractices with all impunity and get away   without   any   legal   consequences   as   if   there   is   an   absolute   immunity.   The Government, Medical Council of India and the health regulatory has to see that licence to practice medicine will not become licence to kill and extort and come to the rescue of helpless patients.   57.   The appeal is disposed of.  (M. Sridhar Acharyulu)