System failed twice, no one checked: Probe

An accident at Sushruta Trauma Centre was waiting to happen. Three days after four patients died after the oxygen supply system failed for 12 minutes, Health officials on Friday said two of the five ventilator systems in the ICU were malfuntioning over the past three months, but were not repaired.

"We found after an inspection that the compressors of two ventilators in the ICU were not functioning properly. The hospital administration knew about this problem and was sitting on it for at least three months. The problem was not addressed," a senior official said.

Health Minister Dr A K Walia constituted a three-member inquiry committee on Tuesday and the report was submitted to Lieutenant Governor Tejendra Khanna on Friday.

Sources said the report blamed the hospital administration as well as the private contractor, PES Installations Private Ltd, which was hired to supply oxygen to the ICU and maintain the centralised system.

The oxygen supply system malfunctioned twice, hours before the fatal incident. "There were problems on Monday afternoon and after midnight on Tuesday. An alert was sounded on both occasions and the technician was told to fix the problem. But no remedial action was taken," a government official said.

At 6.45 am on Tuesday, oxygen supply to the ICU failed - suffocating four critically ill trauma patients to death. A fifth person died of a cardiac arrest the following day.

A Health official said the trauma centre authorities never checked the private company's work. "The oxygen supply system was outsourced to the private contractor in 1998. We found, after speaking with the hospital staff, that no one ever checked the company. This is very dangerous," he said.

The contractor was summoned under Section 91 of CrPC on Friday for questioning. The police have arrested two company employees so far.

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