5 yrs after tragedy, Sushruta learns no lessons

and delay in payment to the company supplying oxygen led to the death of five patients on ventilators at Delhi government’s Sushruta Trauma Centre in 2012. Five years later, nothing has changed.

The hospital still uses an obsolete gas pipeline system, the investigation into the role of six doctors is still pending with the state medical council and the company that supplied oxygen to the hospital still has contract with government hospitals.

HT took a look at the Delhi incident days after 60 children reportedly died for the want of oxygen in Gorakhpur’s BRD hospital.

“In the 2012 incident, oxygen pressure in the central line had dropped and an alarm had gone off. But there was a delay by the technician in switching the cylinders during which the supply was cut off for nearly three minutes. The doctors on duty had at the time resuscitated the patients using Ambu bags for manual ventilation. But, due to the severity of their injuries, they succumbed later in the day,” said Dr Ajay Bahl, medical superintendent of Sushruta Trauma Centre, who was not the chief back then.

A case of negligence had been registered against the company supplying oxygen and manpower to operate the central gas pipeline. “There was delay in payments and the company had started sending only one person for each shift and the technician on duty was not qualified to handle emergencies,” said a doctor who worked in the hospital at that time.

The technician on duty and the supervisor, both from the third party company that was in contract with the hospital, were arrested. The company, which was to be black-listed (meaning it could not do business with other government hospitals), was debarred for 18 months and is now back in business.

“This decision was taken without any investigation and we had challenged it in the court. The fluctuation had happened because the hospital had a very old gas pipeline and we had suggested that it be replaced. This was in fact done by the hospital after the incident,” said the company that was supplying oxygen and manpower to Sushruta Trauma Centre at the time. The person wished to remain anonymous as the matter is still sub-Judice.

Although the old gas pipeline was replaced after the incident, the hospital continues to use obsolete gas pipeline hooked to oxygen cylinders instead of liquid oxygen plant, which is more reliable.

The hospital, however, has started keeping emergency oxygen cylinders in the ICUs and wards now, in case, there is a malfunction.

Immediately after the incident, two specialists from the anaesthesia department, who were on contract with the hospital, had been terminated. They continue to work at other government hospitals as the enquiry on them by the state medical council is still pending.

The police had also recommended that the role of the head of the department of anaesthesia and three others on duty be examined to see whether there was a delay in resuscitation. Even that investigation is pending with the Delhi Medical Council. All four doctors are in service.

“We will be releasing the final report in another ten to fifteen days,” said Dr Girish Tyagi, Registrar and Secretary, Delhi Medical Council.