The police on May 8th 2015, filed a charge sheet against a former senior official of Fortis Hospital, Bannerghatta Road, Bengaluru and a government officer, with reference to a case of organ transplantation, where the patient died after the transplant.

P K Davison, the Facility Director of Fortis Hospital on Bannerghatta Road, Bengaluru, and Dr V Raju, former deputy director (Medical) in the Office of Appropriate Authority for Organ Transplantation, Government of Karnataka are the accused in the case as per the charge sheet. The records reveal that the police have charged them with colluding and committing forgery on Fortis Hospital’s application for the organ transplant surgery license, submitted to the government.

Fortis Hospital’s Bannerghatta Road branch, as per the records available, also lost its licence perform kidney, liver and homograft transplant surgeries less than a year ago. This followed a five-year-long legal battle after the death of a patient due to post-operative complications resulting from a pancreas transplant surgery performed on her. According to the patient’s husband, the surgery was performed without the patient’s or his relatives’ informed consent and a valid license.

The transplant that led to tragic death

According to Major Pankaj Rai, husband of Seema, and as per records, in late 2009, Seema Rai, then 43, suffering from severe diabetes, was undergoing dialysis in Wockhardt Hospital on Bannerghatta road. Her treatment continued into 2010 when Fortis bought this hospital. On April 29th, 2009, she had registered her name for want of a kidney with Zonal Coordination Committee of Karnataka (ZCCK).

Late Seema Rai and her husband Major Pankaj Rai, two months before the surgery leading to her death. Pic courtesy: Pankaj Rai

ZCCK is a body appointed by Government of Karnataka to oversee the implementation of the Transplantation of Human Organs Act of 1994 and to coordinate the cadaveric transplantation activities.
A year later, on May 1st, 2010, ZCCK notified Fortis Hospital on Bannerghatta Road about the availability of a kidney. When the hospital informed Rai’s family about it, Seema Rai was admitted on the same night for a transplant surgery.

After ZCCK notified the hospital that pancreas was also available from the same corpse but had no recipient, Dr. Ramcharan Thiagarajan, the surgeon who was to perform transplant surgery the next day, advised Seema Rai to undergo pancreas transplant surgery as well. She was assured it would take only two extra hours to transplant pancreas along with the kidney.

Major Pankaj Rai, Seema’s husband, says that when Seema Rai was reluctant to give her consent for transplantation of pancreas, she was told she can decide on it after meeting the cardiologist the next day, who would be explaining her all the risks and the benefits. But this meeting never took place, according to the case documents.

The next day, according to Major Pankaj Rai, when he was out of the hospital to procure a certain drug for the surgery, a nurse is said to have asked Seema Rai’s daughter, Abha Rai, then a 21-year-old BA student, who was accompanying her mother, to sign on a form and enter her mother’s initials as well.

This was the consent form, which requires the patient’s signature, as well as that of a witness. The form, Abha Rai said, was taken away from her before she could see what she had signed on, and she was told that the patient had to be taken for “a routine check-up”.

Fortis gave no answer when Citizen Matters wrote to them on May 13th, asking what is their understanding of the circumstances under which Abha Rai signed the form. Rai says when he found out that his wife was in the Operation Theatre, undergoing surgery for transplantation of pancreas, along with kidney, he protested and demanded that the surgery be stopped, saying that consent was never taken, but by then it was too late to stop. While the kidney transplant was carried out successfully, the subsequent pancreas transplant led to complications, as stated in the court documents.

The surgery went on until the next day for 21 hours and needed 26 units of blood due to post-operative complications. Seema was on ventilator till the night of May 6th, after which she expired due to cardiac failure.

Fortis Hospital on Bannerghatta Road. Pic: Pavan Kulkarni

Cancellation of license to perform organ transplant

Following this incident, Rai lodged a complaint with the relevant quasi-judicial body in Karnataka, called Appropriate Authority. This body is constituted under Transplantation of Human Organs and Tissues Act, 1994. It has members from Department of Health and Family Welfare Services. In the complaint, he accused the hospital and the doctors of negligence and of conducting surgery without a valid license and informed consent of the patient.

However, under the direction of Appropriate Authority, Dr V Raju (against whom the charge sheet has now been filed), who was then the Joint Director (Medical), Department of Health and Family Welfare Services, gave a preliminary report concluding that the treatment given to the patient was appropriate and no fault could be found with the hospital, the doctors or its staff.

When Rai’s complaint against Raju’s findings to the Chairman and other members of the Appropriate Authority yielded no change in the verdict, he approached Karnataka’s anti-corruption watchdog, the Lokayukta. After an investigation, Lokayukta wrote a letter to the Appropriate Authority, highlighting that the findings by the Lokayukta to investigate the issue differed from that of Appropriate Authority.
After this, Rai filed a writ petition in the Karnataka High Court, following which the court quashed Appropriate Authority’s order in September 2011 and instructed it to consider the matter afresh. Following a fresh inquiry, the Appropriate Authority held that Fortis Hospital has conducted the surgery without a valid license and the informed consent of the patient.

As a punishment, it recommended cancellation of the license (formally called Certificate of Registration) given to Fortis Hospital on March 25th 2010, permitting it to perform transplantation of kidney, liver and homograft (permitted usage only).

The matter did not end there. Fortis appealed against it to the High Court, and the order of Appropriate Authority that cancelled the transplant licence was quashed. But Rai did not relent. After a five-year-long legal battle, with many appeals and petitions, the license Fortis Hospital on Bannerghatta Road held for organ transplant was cancelled by Appellate Authority in February 2014.

Although Fortis Hospital filed another writ petition in the High Court challenging this, the court dismissed the petition and upheld the Appellate Authority’s licence-cancellation order by the end of the year 2014.

Meanwhile, in July 2010, Rai had also filed a complaint with Karnataka State Consumer Disputes Redressal Commission, claiming a sum of Rs. 84,55,933. In the month of April 2014, the case was moved to National Consumer Disputes Redressal Commission and remains pending as of now. The amount claimed by Rai for damages has now increased to Rs 6 crores.

Charges of forgery emerge

During the proceedings before the Appropriate Authority, the counsel for Fortis had to defend against a number of accusations, one of which was that the hospital was not licensed to conduct pancreas transplant surgery. The Certificate of Registration for organ transplant granted on March 25th, 2010 makes mention of Liver, Kidney and Homograft (permitted usage only), and not the Pancreas. The charge sheet by the Police discloses that Seema Rai’s death happened after the pancreas transplant.

In defense, the counsel argued before the Appropriate Authority, as recorded in the order given by the Appellate Authority, that the experts required for transplantation of liver and other abdominal organs are the same, and the application form for grant of license to transplant liver and other abdominal organs is the same. Hence, the counsel argued, an application for liver includes “other abdominal organs”, one of which is “pancreas”. This contention was ruled out by the Appropriate Authority.

However, in the proceedings before Appellate Authority, to whom Fortis had appealed against the order given by Appropriate Authority recommending cancellation of its license, as stated in the Appellate Authority’s order, the counsel for Fortis contended: “Our application was for liver and pancreas only which we have specified in the application form”. The application mentioned here was Form 11 which the hospital had submitted to procure the certificate of registration, which is necessary to perform organ transplant surgeries legally.

When this application form submitted by Fortis was produced in the appellate proceeding, the word “pancreas” was in fact present. But on a careful examination, the Appellate Authority noticed that the word “pancreas” below the word “liver” was entered outside the boundary of the column drawn for entering the names of the organs, and white fluid was used to erase a word above “liver”.

Since the Hospital had “at no stage challenged the non-inclusion of pancreas in the list of organs for which certificate of registration was granted”, the Appellate Authority suspected that the word pancreas, “might have been.. entered in the application form much later in the light of the proceedings initiated against the [hospital],” and raised two questions:

• Why was the word “pancreas” not entered in the space cleared by erasure of the word in the said column?
• Why is the word “pancreas” in a handwriting and font size markedly different from the word “liver”?

However, since the focus of this proceeding was on settling the dispute over Appropriate Authority’s order and not investigating the likelihood of a forgery , the Appellate Authority held that there was a need for a criminal investigation to probe the above questions for a definitive finding.

The appellate proceeding concluded that even if the hospital had made an application for pancreas transplant licence,the hospital was not authorised to perform pancreas transplant surgery as pancreas was not included in list of organs for which the certificate of registration was granted,.

‘Form had no word called Pancreas.’

Dr H C Ramesh was the Deputy Medical Director, Department of Health and Family Welfare Services, under whose custody the form for grant of transplant licence was, during his tenure from February 2005 to July 2010. In his written statement to S N Jayaram, the then Commissioner of Department of Health and Family Welfare Services, and the Appropriate Authority, he said that he received the application by Fortis Hospital dated 18-01-2010, for permission under Transplantation of Human Organs Act on 15-02-2010.

He confirmed that in Form-11, which is the application form for the grant of transplant licence, he has seen the words Kidney and Liver, but not Pancreas. “Pancreas in column 4 is a later addition. I do not know the details of persons who have entered the word… At the time of the recipient of application there was no word called Pancreas in column 4,” he stated.

He said he had accompanied the team that inspected the hospital before granting the certificate and was fully aware the committee recommended the registration for Transplantation of Kidney, Liver, Homograft.

“It is a usual practice that other hospitals take separate permission for pancreas transplantation and… Fortis Hospital.. have never asked specifically for the pancreas. The pancreas included in the Form-11 is a later addition,”  he stated. He added that the handwriting of the word ‘Pancreas’ was not that of the case worker who handled this application.

FIR filed against Fortis management and Dr V Raju

Meanwhile, in January 2014, a month before the hearings before the Appellate Authority, Rai had already approached a private forensic lab in Bangalore, to examine form 11, and determine if the handwriting in which the word ‘pancreas’ was written, was of the same person who filled the rest of the form.

After examining the document “under various writing conditions by using several scientific instruments including magnifiers and measuring devices”, the lab, in its report released on January 18th, 2014, determined that  it was “highly probable” that the author of the rest of the words written in the form was “not the same author of dispute writing” (the word “pancreas”).

The needle of suspicion now pointed to Dr Ramesh’s successor Dr V Raju, as the handwriting was different, and Dr Ramesh said the word ‘pancreas’ did not exist in the form when he received it. A month later, on February 28th, 2014, Major Rai filed a FIR in Seshadripuram Police station, alleging that the management of Fortis Hospital had committed forgery in collusion with Dr Raju.

In the complaint, apart from accusing Dr V Raju of forgery, Rai also accused the then Commissioner of Health and Family Welfare Services, retired IAS, D N Nayak for colluding with him, and the Fortis management represented by Malvinder Singh, Chairman of Fortis Healthcare Ltd, Shivinder Singh, Executive Vice-Chairman and Karthik Rajagopal of using forged documents in the proceedings before Appropriate Authority in December 2013.

In support of his arguments, Major Rai stated the following in the FIR:

• Observations in the orders of the Appropriate Authority dated 26-12-2013, stated, “The handwriting and the colour of the ink appear to be inserted and to be verified”.
• Report of the handwriting expert confirms that “Pancreas is not in the handwriting of Dr. Ramcharan Thiagarajan, who filled up the application form for the organ liver.”
• The handwriting is very similar to that of Dr Raju, who was the custodian of the forms after July 2010.

Soon after, Major Rai procured a handwriting sample of Dr V Raju and approached the same private lab, which, after examination, opined in its report on April 20th, 2014 that it was highly probable that the author of the word ‘Pancreas’ in form – 11 and of the writing sample of Dr Raju were the same, and requested a detailed writing sample of the suspect along with all the original documents for further examination and conclusion.

However, the reports from private forensic laboratories are not admissible in courts. Following the confirmation from Central Forensic Laboratory in Madiwala that the handwriting in which the word “pancreas” is entered is that of Dr V Raju, the police have filed a charge sheet against him for forgery and against P K Davison, former Facility Director at Fortis hospital on Bannerghatta road, for colluding with him.

While Dr Raju has secured an anticipatory bail before the charge sheet was filed, P K Davison is absconding, according to police.

Fortis declines to repond

Citizen Matters sent several queries to Fortis on the case, both on the allegation of forgery and on the operation of Seema Rai. “The matter is now for trial before the Courts and the same being sub-judice, commenting anything would be disrespecting the legal framework”, said Raghu Kochar, a spokesperson for the hospital, in an email to Citizen Matters reporter.

Inspector Ravi Prasad, the Station House Officer of Seshadripuram Police Station under whose supervision the charge sheet was filed, told Citizen Matters that Shivinder Singh’s advocate has given a statement to the police outlining the job responsibilities of a Facility Director, according to which, it is not the CEO or the Chairman of Fortis, but rather its former facility director (who was also designated as the Associate Vice President, according to court documents), P K Davison, who can be held responsible for colluding with Dr V Raju in the forgery.

However, the copy of the charge sheet and statements given to the police had no statement by Shivinder Singh. Citizen Matters has been unable to reach Inspector Ravi Prasad for clarification, as he has been transferred to Traffic Department and is currently said to be out of the station.

Major Rai told Citizen Matters that although the charges of colluding with Dr Raju in forgery might be levelled only against the facility director, the Fortis management has produced forged documents in proceedings before Appellate Authority, which amounts to perjury.

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