“On verifying the case records it is seen that Inj.Efcorlin, Inj.Dexona and Inj.Atropin were given to the patient which is usually given for shock which shows that the condition of the patient became very serious in the labour room itself. But that condition was not recorded anywhere in the case sheet. Even though RMO, the Superintendent and a Gynaecologist were available nearby, she neither called the help of doctors nor informed the seriousness of the situation to them. The treatment for this type of bleeding is suturing the lacerations only. The Postmortem report showed that the patient died due to the bleeding from laceration of vagina and cervix. If the lacerations were sutured with the help of other doctors, the bleeding could have been arrested and the doctor could have referred the patient in a stable condition and death could have been prevented. But she simply put a pressure pack into the Vagina and referred the patient in a serious condition with bleeding and she entrusted the reference to the duty doctor and a senior nurse. But it was her duty to refer the patient with all assistance and supervision to a higher centre.