The second inquiry committee here has blamed two doctors, a nurse, and a Class-4 worker for three stillbirths and the death of two newborns on November 23 at Mother Child Hospital, two days after its inauguration.
Gynaecologist Dr Alka Mittal, paediatrician Dr Yogesh Khanna, staff nurse Rajni, and Class-4 employee Kanta Devi, who serve in the health facility attached with Lord Mahavira Civil Hospital, are held guilty in the inquiry of not performing their duty. The inquiry committee of deputy commissioner Rajat Agrawal also found senior medical officer (SMO) Dr RK Karkara inefficient in supervising duties.
Agrawal on Tuesday submitted the detailed inquiry report of all five cases to principal secretary for health Vini Mahajan. It recommends `1 lakh each as compensation to Manjit Kaur of Detwal village and Jaswinder Kaur of Chahal, two of the mothers who had lost their babies that day.
“The report is with the principal secretary for health, and going through it, she will call the guilty for explanation before any action can follow under the service rules and the law,” said health minister Surjit Kumar Jyani. He had suspended Dr Alka Mittal and transferred SMO Dr Karkara the day after the tragedy; and a few days later, shifted Class-4 worker Kanta Devi.
The report states that Dr Alka Mittal, gynecologist on duty that day, was absent from the hospital and had not even reported for her scheduled morning round. It adds that complications could have been avoided in at least two cases, had she assisted the deliveries in person.
Pediatrician Dr Khanna was found negligent in one case, since he was absent during the surgery upon Manjeet Kaur, forcing Dr Manjit Bajwa to delay her caesarean section until 6pm on November 23. The patient had been admitted to the hospital at 11.55am.
Staff nurse Rajni was found guilty in the case of Jaswinder Kaur, as she tried to handle the complications on her own and went ahead with normal delivery, instead of informing the doctor, who would have opted for surgery. The report states that the nurse was overburdened that day, as she had five deliveries to assist.
Class-IV employee Kanta Devi, the report said, executed a task that wasn’t in her work domain. The report further states that SMO Dr RK Karkara was out of station on emergency leave of absence on the afternoon of November 23, and none of the team doctors informed him about the cases. While he can’t be held responsible for the chain of events directly, the inquiry committee concluded, he had been inefficient supervisor.
Who gets clean chit
In the detailed inquiry report, the coordination between patients and the ANM (auxiliary nurse and midwife) and ASHA (accredited social health activist) worker was found satisfactory. The ante-natal check-up and other required tests were on time and medicines administered to the patient. The 108 ambulance service was also found up to the mark.
Difference in reports
The findings of the deputy commissioner’s committee are different from the observations of the preliminary inquiry team of special health secretary Vikas Garg and director of welfare Dr Jatinder Kaur.
The first team had held Dr Alka Mittal responsible in the cases of Reena Rani and Vandana, saying the doctor should have assisted those deliveries.
The DC’s detailed inquiry report filed on Tuesday has found doctors negligent in the cases of Jaswinder Kaur and Manjeet Kaur. If the first case, the staff nurse underestimated the complications and did not call the doctor; and in the second, doctor was alerted an hour late, at 1pm, followed by another call at 3pm. The doctor walked in at 4pm.
Confronted about the difference in the two reports, DC Rajat Agrawal said he would stick to his team’s findings.
“We have collected every minute detail about the hospital staff and the affected families.”
Dr Alka Mittal, gynaecologist, was absent from duty, could have saved two babies
Dr Yogesh Khanna, paediatrician, his absence delayed an operation by almost 6 hours
Rajni, staff nurse, played doctor, went ahead with normal delivery in one case where surgery was required
Kanta Devi, Class-4 employee, executed a task outside her work domain
Rs 1 lakh each as compensation to two of the five women who lost babies that day
Recruitment of more doctors and staff nurses at the hospital to handle more than 500 deliveries a month
More operating theatres and other facilities
Appointment of a public relations officer for coordinating with the media (on November 23, journalists had barged into operating theatre without permission).