4 die as oxygen supply stops at trauma centre

Hospital
Health Minister orders inquiry Sushruta Trauma Centre blames private contractor Police register case of death due to negligence

Four patients on ventilator support at Delhi government's Sushruta Trauma Centre in North Delhi died early on Tuesday after oxygen supply in the ICU was apparently cut off for 12 minutes.

Hospital authorities said the contractor in charge of maintaining oxygen supply failed to ensure that there were enough back-up cylinders when the cylinder supplying oxygen ran out.

Health Minister Dr A K Walia said a three-member inquiry has been set up under the Special Secretary, Health, to investigate the deaths. A report will be submitted in three days.

The hospital is also conducting an inquiry under the head of the anaesthesia department at the Maulana Azad Medical College.

"The inquiry, headed by S B Shashank, Special Secretary (Health), will look into the causes of the incident, possible faults on the part of the company and our own staff, and the responsibilities of the anaesthesia department," Dr Walia said.

Additional Medical Superintendent of Sushruta Trauma Centre Dr Vikas Rampal said oxygen supply was first snapped for five to seven minutes since the pressure in the only cylinder in service was critically low.

"It took the representative of the private company another five minutes to replace the cylinder. The installation, management and maintenance of the oxygen supply system is with PES Installations Private Limited, in Punjabi Bagh," Dr Rampal said.

By the time supply was restored, Rihaana (36) and another 36-year-old unidentified patient recovering from a surgery after a head injury; and Javed (20) and Rajkumari (35) — both admitted for poisoning — had died.

A fifth patient, Vikram, who was also admitted in the six-bed ICU, was saved.

Rajkumari's husband Ram Babu said his wife was admitted on Friday. "My wife's condition was improving. On Monday night, the doctor said she would be discharged in a couple of days," he said.

He was informed of his wife's death around 7.30 am on Tuesday.

Dr Rampal said the hospital has 11 oxygen cylinders on one side of the ICU, and another 10 on the other. At a time, all cylinders of either of the groups should be functional, Dr Rampal said.

"But we found on preliminary inquiry that, on Monday night, only one cylinder was working," he said.

A senior doctor in the anaesthesia department said that at 6.40 am, all the ICU alarms went off. "The sister on duty saw one of the patients collapsing, so she attempted to resuscitate him. Within seconds, she realised that there was no oxygen supply," he said.

After the ICU staff alerted the representative of the private company, he came to the ICU and took at least five minutes to replace the single cylinder, hospital staff said.

Dr Rampal said a cylinder works only for an hour to 90 minutes. He said according to the arrangement, the private contractor is supposed to provide a staff of nine people during the day and three at night, including one technician.

"We pay them a monthly sum of Rs 80,000. But on Monday night, only a single helper was in the hospital. This company representative, who is a helper, said he was never told that all the cylinders were supposed to be working at a time," Dr Rampal said.

He said in the inquiries it emerged that six people, instead of the mandatory nine, from the company had been reporting during morning hours.

Sources in the hospital ICU said there had been warnings of supply problems on Monday, when the pressure system in the oxygen supply had gone down twice.

"Twice, when emergency surgeries were on, the pressure in the oxygen cylinders went down — at 2.30 pm and at 3 am on Tuesday. Supply was restored after we complained," a hospital staff said.

Dr Rampal confirmed that there had been two such incidents in the operation theatres, but no action was taken by the company.

The government has called for a meeting on Wednesday to review the oxygen supply systems in all hospitals.

On the complaint of Dr Rampal, police filed a case under IPC Sections 287(negligence) and 304A (causing death by negligence) against PES Installments Private Limited.

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