On December 24, 2018, the counsel for the Justice Arumughasamy Commission, formed to probe the circumstances surrounding late CM J Jayalalithaa's death, made stunning allegations of medical negligence and criminal conspiracy in her treatment. The Standing Counsel for the Commission locked horns with Apollo Hospitals by serving a petition accusing the hospital of colluding with VK Sasikala to not provide Jayalalithaa with the 'best recommended treatment'. The standing counsel alleged that failing to carry out an angiogram on the leader led to her health deteriorating and subsequent death. The current Health Secretary J Radhakrishnan also came under the Standing Counsel's line of fire for his alleged failure to convey details of the treatment to the cabinet of ministers. According to the Commission, proper communication could have helped the cabinet take a decision on ferrying her abroad for medical care.

However, depositions of multiple senior doctors before the Commission, exclusively accessed by TNM, show that these allegations are contrary to the majority of medical opinions. A large number of senior medical practitioners treating her were against performing an angiogram as it could worsen Jayalalithaa's condition. Further, Jayalalithaa herself refused to travel abroad for further treatment, according to the depositions.

Amongst the doctors who ruled out the need to immediately perform an angiogram on Jayalalithaa were Padma Bhushan awardee cardio-thoracic surgeon Dr R Girinath, senior pulmonologist Dr Babu Abraham, cardiologist LF Sridhar of Apollo Hospitals, senior cardiologist Dr KM Mathew of Apollo Hospitals also known as the 'father of angioplasty', Dr Nitish Naik of AIIMS, cardiologist Dr Stuart Russel of Johns Hopkins and UK-based intensivist Dr Richard Beale.

'Surgery would have worsened condition'

The former Chief Minister, according to medical records presented to the Commission, had a 14mm long vegetative growth on her heart valve since 2015. The vegetative growth may have impeded the functioning of the heart valve, preventing it from closing properly. The growth, as a result, may have caused a leak in Jayalalithaa’s heart.

This growth has proven to be a thorny issue, with the Commission questioning multiple doctors about why it was not removed through a surgical procedure and blaming the non-removal for the cardiac arrest that eventually led to Jayalalithaa's death.

According to the depositions in TNM's possession, doctors have told the Commission that the vegetative growth, which was due to a bacterial infection, was being controlled by antibiotics, and that her final cardiac arrest was due to acute respiratory distress syndrome (ARDS). But the Commission repeatedly stressed on the need for an angiogram.

A coronary angiogram is a special X-ray test which is done to find out if coronary arteries are blocked or narrowed, where they are and by how much. An angiogram helps determine if treatment such as angioplasty or stent, coronary artery bypass surgery (CABG) or medical therapy is required.

In his deposition in front of the Commission, Dr Girinath has said, "There was a vegetative growth that was less than one centimetre in Amma's heart. When a similar ECHO was done a year back (2015), leakage was observed. But it was not much...There was no need for surgery then. This time, Dr KM Cherian and I looked through reports, the ECHO test and other documents. We both decided that we should not perform the heart surgery."

When asked why this decision was taken, the senior pulmonologist said, “The vegetative growth was over 10 mm long but size does not matter. It is wrong to say that surgery was necessary since there was a perforation in her heart. The perforation was mild and therefore the bleeding too was mild.”

The Commission, relying on the European Society of Cardiology’s Guidelines 2015, then pointed out to the senior doctor that there was a danger of growth bursting and mixing with the blood. The guidelines state that, “surgery must be performed on an emergency basis, irrespective of the status of infection”. But the specialist retorted, "When the vegetation is flat, there are no chances of it bursting. If it stands up straight like a nail there is a chance of that happening...The vegetative growth in Jayalalithaa's heart was not like this."

Dr Girinath admits that three doctors were of the opinion that an angiogram could be done. Dr Stuart Russel from John Hopkins conveyed this through a video call, but no urgency was conveyed. Dr Shamir Sharma, an angio-specialist who had come down from the US for a day said he was ready to do the surgery before he returned.

Another Mumbai-based cardiac surgeon, Dr Soman, had also expressed the need to complete the surgery in the very beginning. But Dr Girinath terms this as an individual opinion. He further adds that more health complications would have risen if the 30-minute-surgery was performed when Jayalalithaa was on the heart and lung machine.

In his deposition, Dr N Ramakrishnan, Director of Critical Care Services in Apollo Hospital, states that, “Dr Shamir, US doctor, held discussions with the Apollo medical team. At that time, Dr Shamir said that at some point, an angiogram had to be done and that he was ready to do the same that day.” However, this was more of a reflection on the fact that the doctor was returning to the US on the next day and was available to perform the surgery only then.

Multiple times in his deposition, Dr Girinath has stressed that Jayalalithaa's ARDS would have made surgery dangerous for her, instead of helping her. He further pointed out that a transesophageal echocardiogram or TEE (an alternative way to perform an echocardiogram) which was conducted did not conclude the need for a surgery.

"If the perforation was big, I would have definitely conducted surgery. But ARDS should not have been there. When a patient has ARDS, around the world, the affected person cannot have surgery. ARDS is a terrible condition and increases mortality from 30 to 90 percent...Amma did not require Angioplasty," he concluded.

In his depositions, Dr Babu Abraham talks about his discussion with UK specialist Richard Beale and their shared conclusions. “I met Amma along with Dr Richard Beale. He accepted completely, the treatment that we were giving to her," he says. "The vegetation in Amma's heart did not grow over 14 mm and she had Mitral Regurgitation (MR). Due to this there was perforation where the heart expands and contracts. The leak however will not lead to any major problems, so we decided we can do the angiogram later,” he told the Commission.

A team of four doctors from AIIMS in Delhi who visited Apollo Hospital on December 3, 2016 for the third time since Jayalalithaa's admission there, concluded that no cardiological investigation was required to aide her present condition.

In the report following the visit, the team consisting of four specialists said, "The cause of hypertension (fluctuations in blood pressure) was unlikely to be due to an endocrine pathology and no invasive cardiologic investigation or intervention was indicated in the present condition.”

The doctors also told the Commission that multiple other specialists including Dr LF Sridhar and Dr KM Cherian had agreed that the surgery to remove the vegetation would create more dangers to Jayalalithaa's health than help her.

Jaya refused to go abroad

The Commission's standing counsel has come down hard on Health secretary J Radhakrishnan for claiming that sending Jayalalithaa abroad was akin to insulting Indian doctors. It said that experts from abroad were flown to Chennai for consulting on the treatment, which contradicts the sentiments expressed by the Health Secretary in his submissions. He has further been accused of not sending reports on her condition to senior ministers, which in turn would have helped the cabinet take a decision 'to airlift her for further and better treatment abroad with the help of the central government'.

The depositions available with TNM however show that sending the then CM abroad for treatment was never the hospital or Health Secretary's decision to make. It was Jayalalithaa herself, according to Apollo doctors, who refused to travel abroad for treatment. What’s more, a senior minister from the cabinet was present when the discussion was first initiated, according to a doctor.

In his deposition Dr Senthil Kumar, chief of the critical care unit in Apollo hospitals, states that till the third week of October 2016, Jayalalithaa's health would not accommodate travel to hospitals abroad. It was after this that the hospital broached the topic with government officials. Health minister Vijayabhaskar was part of this discussion, according to the doctor. This is in direct contradiction to the claim made by Law Minister CVe Shanmugam, that the cabinet were completely unaware of any deliberation on shifting the late Chief Minister abroad for treatment.

“In the third week of October, when the Hospital discussed this, Minister Vijayabhaskar, the Health Secretary, Chief Secretary and other higher officials were present there. But they said that madam (Jayalalithaa) will not accept this (travelling abroad)," says Dr Senthil Kumar. "London doctor Richard Beale directly spoke to Amma about getting treatment abroad. When he came out, he said that she refused to do this," he said.

Dr Babu Abraham also backs this version. “Dr Richard Beale told me he spoke to Amma and Sasikala about going abroad for treatment. He came out and said ‘Very strong-willed lady. I could not convince her to shift abroad'," he said. He further adds that he was not shocked by this decision, as Apollo Hospitals offers superior nursing care.