Chima & Ibrahim

Advocates
Corporate Counsel

1-A/245 Tufail Road Telephones : (9242) 36681265-7

Lahore Cantt, Pakistan Telefax : (9242) 36687790

WITHOUT PREJUDICE

December 15, 2009

Mr. Waseem Akram

64/2, Z Block
DHA, Lahore

Subject : Legal Notice

Dear Sir :

We have instructions from our client, Dr. Kamran Chima of 10-A

Upper Mall, Lahore, to address you as under :

1. Our client is an American Board certified pulmonologist and

critical care specialist, presently associated with the Services Hospital Lahore,
and the Doctors Hospital Lahore. It may also be mentioned that he was the
best graduate of King Edward Medical College (from where he graduated in
1986) and completed his specialized training from the Yale University, USA.

2. Our client has been practicing in Lahore since 1994. The

love and affection extended by his patients is not only
touching, but also sufficient to establish the immaculate
reputation our client enjoys.

3. Your late wife (Mrs. Huma Akram) was admitted to the

National Hospital Defense Lahore (“National Hospital”) on 6
October 2009, on account of multiple ailments. She was
attended to by a team of doctors associated with the National
Hospital, who looked after her ably and with all requisite
attention. However, it is worth noting that our client (not being
associated with the National Hospital) was not among them.

4. Our client was asked to see Mrs. Akram, by way of

special request extended by Dr. Nauman Tareef. The request
was made at 23.43 hrs on 14.10.09. Our client was well within
his rights to decline the request, considering how late in the

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evening it was made, and the fact that he was not even
associated with the National Hospital (and was not therefore
obligated to accept the request). However, our client virtually
immediately rushed to the National Hospital and saw Mrs.
Akram for the first time at the rather unearthly hour of 00:45
AM (i.e. in the early hours of 15.10.09). After thorough
examination of the patient (and all her medical records made
available to our client), our client’s assessment/diagnosis was
that she was suffering from ‘endovascular infection/infective
endocarditis’. Incidentally, that diagnosis remains correct
(though the actual organism suspected of causing the
infection was identified after the patient’s death).

5. Our client was then kept advised of the patient’s

progress throughout the day, by Dr. Nauman Tareef. There are
no less than 5 calls between our client and Dr. Tareef on
15.10.09.

6. During the course of 16.10.09, the doctors treating Mrs.

Akram at National Hospital felt that due to possible infection in
her heart valve it may need to be replaced and it could not be
done in the National Hospital (which does not have facilities
for such valve replacement). Our client (who specializes in
critical care treatment) was requested by Dr. Nauman Tareef
to assist the move to the Doctors Hospital as well as the
requisite procedure.

Since you have wantonly suggested in your statements to the

press (including on 10.12.2009) that doctors were not
available as and when necessary, it is relevant to set out the
chronology of calls/events in this behalf (all substantiated by
telephone records attached as Annex A to this legal notice) :

i. Our client receives call from Dr. Nauman Tareef on

16.10.09 at 20:48 (through this call Dr. Tareef requested that
the patient be shifted from National Hospital to Doctors
Hospital).

ii. Our client immediately (at 20:54) calls Dr. Sobia Kazi
at Doctors Hospital to alert her of the patient’s anticipated
admission.

iii. A follow up call is made to Dr. Sobia Kazi at 20:59.

iv. Two calls are then made to Dr. Tareef (at 21:02 and
21:09) to confirm that arrangements have been made.

v. Incoming SMS is received from yourself (Waseem

Akram) at 21:44 on 16.10.09.

vi. Our client calls you (Waseem Akram) at 23:17. In this

call our client also makes it very clear to you that if you

2
decide to shift Mrs. Akram to Doctors Hospital, her dialysis
would be supervised by Dr. Abeera Mansur. (It may also be
mentioned here that our client has full confidence in the
professional capabilities of Dr. Abeera)

vii. A call is received from Dr. Tareef at 23:37, in which

arrangements are discussed and confirmed.

viii. An SMS is received from yourself (Waseem Akram) at

00:47 on 17.10.09, informing our client that Mrs. Akram has
arrived at the Doctors Hospital.

ix. Our client, who was already on his way, reaches the
hospital minutes later and remains with the patient for 60
minutes.

x. Our client sends an SMS to Dr. Asad Jawad at 02:01

hours (regarding the procedure Mrs. Akram may need to
undergo later in the morning). This SMS was sent while our
client was at the Doctors Hospital.

xi. Our client then calls Dr. Asad Jawad at 07:56.

Considering that our client was in Doctors Hospital at least
until 02:30 or so (his last message to Dr. Asad Jawad is
recorded at 02:01 hours), you can well imagine that he could
not have had more than 4 ½ hours of sleep before he was
back on the case. All this, incidentally, on Friday
night/Saturday morning – when most people would be
enjoying their weekend.

xii. 11 further calls are then recorded between 7:56 and

11:44, in a period of less than 4 hours (which were made by
our client to various doctors seeing Mrs. Akram, including Dr.
Asad Jawad, Dr. Sobia Qazi, Dr. Abeera Mansur, Dr. Sarwar
and Dr. Nauman Tareef).

xiii. At 11:49, a call was then made by our client to you

(Waseem Akram), informing you of the doctors’ consensus
that before executing heart valve replacement, it was
advisable to get further testing from the Punjab Institute of
Cardiology (“PIC”). The TEE test at PIC in fact showed that
valve replacement was not necessary (CD of the test is
available with you), and the patient was shifted to Heart and
Body Scan for further testing.

xiv. While the patient was undergoing testing at PIC, and

thereafter ‘total body scanning and CT angiography of
kidneys and abdomen’ at Heart and Body Scan (during the
latter phase our client was personally present with the
patient), and during the rest of the day, our client made 6
further calls to various doctors seeing Mrs. Akram (including
Dr. Sobia Qazi, Dr. Faisal Sultan CEO SKMT, Dr. Nauman
Tareef, Dr. Arifeen and Dr. Abeera Mansur). This is in addition
to being personally present with the patient during most of
that time.

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 xv. It is also noteworthy that despite spending most of the
day with the patient on 17 October 2009 (which was a
Saturday), our client sent an SMS to Mrs. Bakhtiar Wain at
21:09, regretting that he would not be able to make it to the
dinner she was hosting, though he had earlier confirmed
participation. Why? Because he was working on stabilizing
Mrs. Akram (no favor to you, as our client has done this on
countless other occasions as well).

xvi. In fact, our client did not leave the patient until her
condition was stabilized. Once that had been done (and she
in fact remained stable during the rest of her stay in Doctors
Hospital) most of our client’s work (as critical care specialist)
had been accomplished. However, he regularly kept seeing
the patient during subsequent days as well, as noted below.

7. In the afternoon of 17.10.09, you informed our client that (on

the insistence of your in-laws) you had made arrangements to
shift the patient to Mount Elizabeth Hospital in Singapore. Our
client, as well as Dr. Faisal Sultan (CEO SKMT), Dr. Abeera
Mansur and Dr. Sobia Qazi advised you that in their reckoning
NUS Hospital was the best hospital in Singapore. However,
you indicated that arrangement had been made by ESPN.

It was in the aforesaid context that our client mentioned to

you in passing, that one of his patients was taken to the world
renowned Cromwell Hospital in 2008, and to our client’s
recollection the air ambulance charged approximately USD
125,000. This was meant to inform you of your options, and
nothing more. The issue was never discussed or mentioned
thereafter (though one would have thought that most people
in your situation would pay the extra amount to ensure their
wife was taken to the hospital which is amongst the very best
reputed in the world – it perplexes one that you did not
consider the option).

Be that as it may, it may be noted that the other patient’s

family who arranged the aforesaid air ambulance service, has
kindly permitted our client to disclose the invoice, which is
attached as Annex B. It shows a charge of EURO 86,500
(which in US Dollar terms would come to what our client
roughly indicated).

In your recent and entirely unfounded outpouring, you have

alleged that our client asked for USD 150,000 to arrange air

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 ambulance service for Mrs. Akram. The allegation is absolutely
incorrect. Our client also fails to understand the relevance of
this allegation, considering that you arranged the ambulance
service entirely on your own. It may though be noted that
neither our client nor Doctors Hospital is in any manner
involved in arranging air ambulance service. They have never
done this before, and do not intend to go into this business for
the future either. On the one previous occasion when this was
done in our client’s knowledge, this was entirely arranged by
the patient’s family. It would also be rather stupid of anyone
to ask for a commission in this regard, considering that air
ambulance can be booked directly from the internet.

8. Coming back to the chronology of events, the next day, which

was 18.10.2009 (and a Sunday), our client received an SMS
from yourself at 13:50, and then immediately thereafter a call
from you at 13:54. Our client proceeded to the hospital to see
Mrs. Akram and spent most of the day in Doctors Hospital,
seeing Mrs. Akram as well as other patients.

9. On 19.10.09 (which was a working day, and our client was in

Services Hospital during the first half), he not only kept in
touch with doctors at Doctors Hospital, but also personally
visited the patient in the afternoon. You had already, on your
own initiative, made arrangements to shift the patient to
Singapore, which you confirmed to our client. Even though
neither the hospital in Singapore nor the air ambulance
service had requested our client in this behalf, he prepared a
rather detailed summary of her medical history – which was
handed over to you in the evening on 19.10.09. This shows
the commitment with which our client was ensuring the well
being of his patient. Incidentally, the same day another of our
client’s patients (the mother of his very dear friend, and sister
of Justice (R) Naseem Hassan Shah) became critically ill, and
died despite efforts to revive her – so the aforesaid summary
was prepared despite other claims on our client’s time.

10. Our client’s last call to you was at 22:18 on 19.10.2009 -

incidentally the record establishes that this was not in
response to an SMS from yourself. During this call, you
profusely thanked our client for all the help extended to you
and your family. You also confirmed receipt of the medical
summary prepared by our client and thanked him for it. You
confirmed that the team from Singapore had arrived to assess
the patient, and that you would be flying out at 2 AM. Our

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 client later found out that you did not in fact fly out at 2 AM,
but at 10 AM.

11. With this record of commitment and service, it is surely

laughable for anyone to suggest that our client was not
available when required. The record would show that there is
not a single SMS by you to our client which was not instantly
responded (either by personal visit or telephone call or both).
It may just be worth mentioning that our client’s wife was in
the USA at the relevant time, and our client was also
entrusted with the care of their 9 year old son – which our
client totally compromised during those days.

Our client would like to record the fact that he was impressed
by your devotion to Mrs. Akram. Every time our client visited
her (even at odd hours) he always found you to be there.
Perhaps you feel that our client should also have devoted as
much time to Mrs. Akram as yourself – if so, the expectation is
unrealistic.

12. Our client understands the subsequent events to be as follows

(these are gleaned from the Brief Report issued by the Inquiry
Commission – though it has to be said that our client has not
formally received a copy; moreover our client disagrees with
some of the findings and reserves the right to challenge the
same) :

“HOPE AIR AMBULANCE: She developed serious distress

and restlessness in the air, most likely due to low
oxygen at high altitude. In order to treat her
restlessness she was given intravenous diazepam. This
might have been the last straw. She immediately
developed cardiopulmonary arrest. She underwent a
long resuscitation effort lasting ½ an hour. Her
heartbeat recovered but she had by then suffered
irreversible brainstem injury. The plane landed in
emergency at Chennai, India, and she was admitted to
the Apollo Hospital.

APOLLO HOSPITAL, CHENNAI : At the time of admission

she required breathing support, and had severe
brainstem damage. She developed skin blisters on 23rd

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 October 2009 for which deep biopsies of skin and
subcutaneous tissue were obtained from thigh next day.
She died on 25th October without a firm diagnosis. She
was however put on empirical antifungal treatment as a
part of protocol for treating fungal infections. A report of
the skin biopsy which was issued two days after her
death which revealed extensive fungal infection ie
Mucormycosis that had blocked all her blood vessels in
the subcutaneous tissue.”

The inquiry report also records :

“Ironically even the ambulance team apparently did not

have senior consultant to adequately evaluate the
status of the patient.”

13. Before one proceeds further, it needs to be noted that

according to the Indian test reports Mrs. Akram died due to
the “Mucormycosis” infection. According to Mandell, Douglas,
and Bennett’s Principles and Practice of Infectious Diseases
(7th Edition) (Annex C) :

“Disseminated mucormycosis is rarely apparent

before death …. Blood cultures are nearly always
negative … biopsy of the suspected site is critical
for diagnosis of the infection.”

As noted in the inquiry report, biopsy was only possible once

the patient developed skin blisters on 23 October (which was
after she left Pakistan).

This establishes that no one can be blamed for not diagnosing

this particular infection – and least of all, our client, who is not
an Infectious Diseases expert, and whose only job was to
stabilize the patient (as a critical care specialist) which he did.

It may also be pertinent to quote from the conclusion recorded

by the Inquiry Team :

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 “CONCLUSION : Systemic Mucormycosis is a deadly
disease and can occur in bicuspid aortic valve with very
high mortality.”

As you know, your late wife also had a congenital heart defect
(noted above), which placed her in the category with
particularly poor prognosis in respect of such disease.

14. Ever since the tragic death of your wife (for which no blame
can attach to any doctor who saw her in Pakistan), our client
and all other doctors involved in her treatment have been
subjected to baseless and ridiculous defamatory and
scurrilous allegations. Our client has resisted the urge to set
the record straight, attributing your lack of reason to an
understandable grief which may have caused you to be
emotionally disturbed. Understanding your grief, our client did
not want to aggravate it by confronting you – notwithstanding
that your baseless and entirely unfounded utterances (which
have received vast coverage in the print and electronic media,
as well as on the internet, both in Pakistan and abroad) were
impacting our client’s good name and reputation. However,
our client considers that this has gone on too far and long, and
the record needs to be corrected!

15. The irresponsible allegations made by you include the

following :

i. Doctors were not available, even on the phone.

ii. Our client asked you for USD 150,000/- to arrange air
ambulance.

iii. Our client was negligent in allowing Mrs. Akram to be

shifted to Singapore by air ambulance.

iv. Mrs. Akram died on account of negligence by the doctors

in Pakistan.

16. While the first (at least so far as it is applicable to our client)
and the second have been sufficiently addressed above, it is
also important to counter the remaining two, which as well are
equally baseless.

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17. Whether our client was negligent in allowing Mrs. Akram to be
shifted to Singapore by air ambulance?

This allegation is best answered in light of the following

questions.

17.1 What was the prognosis if she stayed in Pakistan?

The fact is that there was no clear ascertainment of the

organism that caused the infection. There was a suggestion
made by Dr. Faisal Sultan (who is Lahore’s senior most
Infectious Diseases expert, and CEO of SKMT) that she was
possibly suffering from ‘Hanta’ virus, which cannot be
diagnosed or treated in Pakistan. It thus seemed that her best
chance was to go to a place where such diagnosis and
treatment could take place.

As noted by the inquiry committee report, even the hospital in

India was not able to identify the organism until two days after
her death.

17.2 Would the outcome have been any different had she stayed in
Pakistan?

For reasons noted in paragraph 13 above, the answer to this

question quite categorically is that the outcome would have
been no different.

In fact, our client finds it very strange that on the one hand,
you are accusing doctors in Pakistan of negligence for not
being able to fully diagnose and treat your late wife (the
charge of course is baseless), and on the other hand and in
the same breath, you are accusing our client for not stopping
her from leaving these very doctors that you are otherwise
accusing!

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17.3 Would it have been proper for our client and/or The Doctors
Hospital to stop her?

Considering that (i) there was no clear identification of the

infecting organism; (ii) there was a plausible diagnosis which
recommended that she be shifted without delay; and (iii) you
and the patient herself wanted to shift to Singapore (all
arrangements in this behalf were made by yourself), it would
have been unethical to detain her in The Doctors Hospital.

17.4 Was she stable to travel?

It may be noted that she was not only conscious and

breathing on her own but was also able to walk around on her
own, and there was no circumstance that would have
suggested she was not stable to travel in an air ambulance
equipped with all necessary equipment and accompanied by
highly trained physician(s) and nurse(s). Her condition from
this perspective had improved since she was shifted to the
Doctors Hospital, though of course she continued to suffer
from (as yet undetected organism, but nevertheless) lethal
infection. It may be noted in this behalf that throughout her
stay in Doctors Hospital, Mrs. Akram was in a private room
(and not in the ICU) – which itself establishes that she was fit
to travel under specialized care as noted above. In fact such
travel would have meant that she would be shifted to an ICU
(which is what the air ambulance was meant to be) instead of
a private room.

Also, this needs to be noted in light of the following

representations issued by most air ambulance services,
including the one that you actually engaged (in fact the
following statements are taken from website of Hope Air
Ambulance service – Annex D) :

- Inside the air ambulance are life support systems,

oxygen, monitors and emergency drugs. A highly
trained physician and nurse escort team will
accompany and treat the patient throughout the flight
[Highlighting is theirs]

- However, when a patient is critically ill or requires

round the clock medical care .. the options for travel

10
 become limited to traveling with specially equipped
and qualified doctor and nurse escorts. This is what
Hope Air Ambulance specializes in.

- Advance Life Support medical equipping

• Ventilator (critical care, multi mode)

• Multi-parameter monitoring (including invasive

line and EtCO2)

• Defibrillator

• Pacing (TCP)

• Airway management (including emergency

surgical airway)

• Drug (cardiac, resuscitation, anaesthetic,

analgesia, etc.)

• Vaccum immobilization

• Suction

• Syringe and infusion pumps

• Special pediatric, trauma, burns, kits, etc.

- Infectious Disease Transfers

Hope Air Ambulance has an extensive array of

equipment and drugs that allows us to handle the
entire spectrum of critically ill patients … from
major trauma to heart attacks and patients on
full life support etc.

- Our medical professionals are experienced, calm and

versatile individuals

• Specialist physicians (emergency physicians,

intenservists and anaesthetists)

• Physician escorts (ICU, flight and

emergency trained)

• Nurses (Critical care and emergency

qualified)

• Paramedics

The vast experience of our teams includes hundreds of

flights ….

- Management : Theresa Yeap, Josephine Ham and

Charles Johnson together run Hope Air Ambulance Pte
Ltd. Charles is an emergency physician and a fellow of

11
 the Royal College of Surgeons (Edinburgh) and Theresa
and Josephine are critical care registered nurses. They
each have more than 15 years hospital, ICU,
emergency and flight experience.

- Quality Assurance : Hope Medflight has a firm

commitment to quality assurance and is Singapore’s
only private ambulance organization that is ISO
(9001/2000) certified in road ambulance, air
ambulance, home healthcare and emergency medical
training.

- Our Promise of Care : Hope ambulance stands

behind and guarantees the quality of service we
provide.

- Success Stories :

• Hope Medflight team transferred an elderly

patient from San Francisco to Jakarta. The patient
was on life support (ventilator). To prepare for the
flight, our physicians had to liaise with the US
treating physician ………. Our doctor and nurse
team flew to the US 24 hours earlier to assess and
prepare the patient for long flight. The oxygen and
power requirements had to be calculated and
confirmed. Finally, family members were briefed on
all eventualities. The flight was smooth and the
patient stable. He was continually monitored. The
flight included a transit stop at Korea and a change
of aircraft at Singapore.

• Hope transfers by Learjet a severely ill teenage

boy with dengue fever and respiratory and renal
failure. His blood pressure was unstable and
required multiple drug infusion inflight. He required
a ventilator and dialysis, with long stay in ICU. The
determined young man recovered to return to
Indonesia completely well.

• In Oct 2009, we do a commercial medical

repatriation from Brazil to Manila. The patient
requires full ICU like set up inside the commercial
airliner.

• A young lady on a cycling expedition in Vietnam

has an accident and sustains severe head injury. …
the van is converted to an ambulance with our
portable life support equipment. We fly back to
Singapore with the cabin pressurized to sea
level.

This establishes that if the aforesaid representations are

12
 indeed correct (and of course if they are not, only Hope Air
Ambulance Service would need to answer), there was no risk
to the patient from such travel – as she would have traveled
‘with cabin pressurized to sea level’, with all the possible
equipment that may have been required (including
ventilators, oxygen, etc. – it is specifically noted that “Hope
Air Ambulance has an extensive array of equipment and drugs
that allows us to handle the entire spectrum of critically ill
patients … from major trauma to heart attacks and patients
on full life support”) and ‘highly trained physician and nurse
escort team’. Moreover, the physician is stated (on the
website) to be qualified for critical care, so there was going to
be no reduction in coverage.

17.5 What was the responsibility of the air ambulance?

As noted above, there was every reason to believe that Mrs.

Akram was fit and stable to travel, particularly under
specialized medical care. However, it is also important to note
the following representation made by Hope Air Ambulance
Service :

- “However, when a patient is critically ill or

requires round the clock medical care .. the options for
travel become limited to traveling with specially
equipped and qualified doctor and nurse escorts. This is
what Hope Air Ambulance specializes in.”

- Hope Air Ambulance has an extensive array of

equipment and drugs that allows us to handle the
entire spectrum of critically ill patients … from
major trauma to heart attacks and patients on full
life support etc.

- “Our doctor and nurse team flew to the US 24 H

earlier to assess and prepare the patient for the long
flight. The oxygen and power requirements had to be
calculated and confirmed. Finally, family members were
briefed on all eventualities”.

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 Moreover, and even otherwise (according to established
medical practices), it is the responsibility of the accepting
physician (in this case the physician attached to the air
ambulance) to ensure that the patient is fit and stable to
travel to the next facility. Because only he is best able to
evaluate the patient in light of the specific facilities available
to him in the ambulance.

17.6 Did the air ambulance service comply with the aforesaid
representations?

Before one considers this question, it is of course axiomatic

that if they did not, only they are answerable for the lapse.
Unless you consciously negotiated a lesser (discounted)
service which did not entail some of their promised and
essential features. In this behalf, one learns from the inquiry
committee report that :

“Ironically even the ambulance team apparently did not

have senior consultant to adequately evaluate the
status of the patient”.

It also then appears from the inquiry report that the air
ambulance staff was not able to efficiently manage the
patient (by administering intravenous diazepam in the first
place, and/or thereafter once she suffered cardiopulmonary
arrest).

This raises some questions about the actual service that was
ordered. For instance :

i. Did the air ambulance have the facility to ensure

adequate oxygen pressure during the flight – as
represented on the website? If not, why not?

ii. Did the air ambulance come with senior

consultant/critical care specialist, as represented on the
website? If not, why not?

You are best able to answer these in light of your actual

communication with the air ambulance service. One trusts

14
 that you would not deliberately have ordered a ‘discounted
service’ – and that it is ultimately for the air ambulance
service to answer these issues.

However, our client certainly is not to blame in this regard.

18. Was there any negligence by doctors in Pakistan?

Whether one looks at the immediate cause that resulted in

Mrs. Akram’s death (which evidently is mishandling by the air
ambulance staff), or one looks at the fundamental underlying
cause (which was a rare fungal infection), in either scenario it
is more than clear that there is absolutely no negligence by
the doctors in Pakistan. Least of all by our client who is not an
expert on Infectious Diseases. Even still, the question may be
addressed as follows.

18.1 Immediate Cause

The immediate cause recorded by the inquiry committee is as

follows :

“She developed serious distress and restlessness in the

air, most likely due to low oxygen at high altitude. In
order to treat her restlessness she was given
intravenous diazepam. This might have been the last
straw. She immediately developed cardiopulmonary
arrest. She underwent a long resuscitation effort lasting
½ an hour. Her heartbeat recovered but she had by then
suffered irreversible brainstem injury. The plane landed
in emergency at Chennai, India, and she was admitted
to the Apollo Hospital.”

The immediate cause of death therefore was the entirely

unnecessary administration of intravenous diazepam (just
because she was in distress and restless, there was no
justification to administer this), which caused respiratory
arrest and ultimately led to cardiopulmonary arrest. It may be
noted that the patient was in ‘severe distress’, from time to

15
 time, even prior to the flight (as also noted in the summary
prepared by our client), and the ambulance staff should
therefore have been prepared for this (unless of course, you
omitted to provide the summary to them – for which you alone
would be liable).

Needless to add, administration of intravenous diazepam

(which in fact got the ball rolling in a certain direction) was an
independent action by the ambulance team, which cannot at
all be attributed to the doctors in Pakistan.

It is further recorded by the Inquiry Team that : “Ironically

even the ambulance team apparently did not have senior
consultant to adequately evaluate the status of the patient”.
How can the doctors in Pakistan be liable for such lapse,
particularly when you yourself had made arrangement with
this particular service!

18.2 Underlying/ultimate cause

Regardless of the immediate cause (which appears to be

negligence by the ambulance team), the ultimate/underlying
cause was Systemic Mucormycosis. The question then is : did
she have any realistic chance of survival with this infection?
Consider what the Inquiry Committee has recorded :

“CONCLUSION : Systemic Mucormycosis is a deadly

disease and can occur in bicuspid aortic valve with very
high mortality.”

Were miracles then to be expected from doctors in Pakistan!

In any case, in order to get a definitive finding on this issue,

one needs to perform an autopsy with toxic tests of Mrs.
Akram’s body. Without such detailed analysis, it is wholly
unfair and scandalous to accuse anyone of negligence.

18.3 Why were the Infectious Diseases experts in Pakistan unable

16
 to detect the fungal infection?

Although our client is not an expert on Infectious Diseases,

and this question is best addressed by them, the following
points need to be noted in this behalf :

- According to Mandell, Douglas, and Bennett’s

Principles and Practice of Infectious Diseases (7th
Edition) : “Disseminated mucormycosis is rarely
apparent before death …. Blood cultures are
nearly always negative … biopsy of the suspected
site is critical for diagnosis of the infection”

Pakistani doctors can hardly be blamed for failing to

identify an organism that rarely becomes apparent
before death, and even the Indian hospital only
identified the organism after Mrs. Akram’s death.

- It now transpires that Mrs. Akram may not have

revealed her entire and accurate history to the doctors.
For instance (and there may well be other aspects as
well which require further investigation) the patient
withheld the information that she underwent botox
injections. It is speculated by the Inquiry Committee that
this may have been the cause for the infection. Her own
failure to disclose this aspect may therefore have been
responsible for the Infectious Diseases experts not being
alerted towards this possibility.

- Moreover, disseminated mucormycosis with

endocarditis has never been reported in the world
without prior history of certain risk factors, which your
wife denied. The fact that she was diagnosed with this
infection, may well suggest that true history was not
presented to the doctors.

19. The above facts notwithstanding, which have been most fully
in your knowledge at all material times, you have persisted in
generating a media frenzy about the death of Mrs. Akram, and have
accused each and every doctor who saw her (our client not
excepted) of negligence and malpractice. Additionally you have

17
made some charges, as noted above, specifically against our client
as well. All this has not only caused great loss of name and
reputation to our client (as also other doctors), but needless distress
and anxiety to our client as well.

20. You have also influenced the course of the inquiry

proceedings, not least by making entirely inaccurate and
unsubstantiated allegations against the doctors, as well as the
proceedings before the Standing Committee of the National
Assembly (which incidentally took place, and unprecedented
decisions taken without our client or any of the other doctors even
being invited to attend the proceedings – had that been done, the
committee would surely have seen the shallowness of your
allegations).

You are accordingly required through this legal notice to forthwith

tender an unconditional apology to our client, and to withdraw all
the non-sensical and baseless allegations leveled by you including
as noted above. You are further required to pay damages to our
client in the amount of Rs. 100,000,000/- (Rupees One Hundred
Million). Should you fail to tender the apology, the amount of
damages to be claimed by our client shall be Rs. 500,000,000/-
(Rupees Five Hundred Million). In such event, our client would also
proceed to file criminal charges for your entirely irresponsible
conduct. Needless to add, the aforesaid damages (which upon
recovery shall be contributed to the Shaukat Khanum Memorial
Trust Hospital) are on account of loss suffered by our client alone,
and other doctors may of course be pursuing their own remedies in
this behalf.

Very truly yours,

Chima & Ibrahim

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