A district-level inquiry committee probing the death of a 22-year-old woman after a sterilisation procedure at a primary health centre in Kedgaon has found lapses in clinical decision-making and recommended departmental action against two doctors, said officials.
The five-member panel on Monday submitted its report to the district health officials recommending a departmental inquiry against laparoscopic surgeon Dr Anil Kadam and Dr Nilima Lokhande, medical officer at the Kedgaon Primary Health Centre. Besides, a more detailed inquiry should be conducted at a higher level by constituting a panel of specialists, including a gynaecologist, anaesthetist and surgeon, they said.
The probe was ordered following the death of Ranjana Babu Keskar of Khor Village in Daund who underwent a sterilisation procedure at the Kedgaon Primary Health Centre on April 25. Post procedure, Keskar complained of severe abdominal pain and developed heavy bleeding. She died the same day while being shifted to hospital after her condition deteriorated.
The report, a copy of which was seen by HT, stated, “According to the preliminary report, the woman’s death appears to have been caused by internal bleeding in the abdomen during the surgical procedure. Although Dr Kadam is a trained laparoscopic surgeon, it has been observed that he should have assessed the seriousness of the situation and immediately performed a laparotomy, which he failed to do.”
According to officials, on the day of the surgery, Keskar was admitted at 6 am and given pre-medication under the supervision of medical officer Dr Lokhande. The camp began at 8.15 am, and Keskar was operated on after eight other women. The panel noted that soon after surgery; while being shifted to the ward, she complained of dizziness and her blood pressure dropped.
{{/usCountry}}According to officials, on the day of the surgery, Keskar was admitted at 6 am and given pre-medication under the supervision of medical officer Dr Lokhande. The camp began at 8.15 am, and Keskar was operated on after eight other women. The panel noted that soon after surgery; while being shifted to the ward, she complained of dizziness and her blood pressure dropped.
{{/usCountry}}Doctors suspected vasovagal shock and administered atropine, but her condition did not stabilise. Despite this, the report highlights that there was a delay in escalating care. Instead of immediate surgical intervention, an ultrasound was advised and the patient was referred to a private facility — Akshay Nursing Home in Varvand — where she was admitted to the ICU around 11.30 am.
Dr Kadam, who had left for another camp, returned to examine the patient later in the afternoon. He advised shifting her to Sassoon General Hospital, stating that an emergency laparotomy could not be performed at the private hospital. However, by then, her condition had worsened and she died around 6 pm on her way to Sassoon.
The preliminary medical report issued by BJ Medical College and Sassoon General Hospital attributed the death to “haemorrhagic shock due to intra-peritoneal haemorrhage in an operated case of laparoscopic sterilisation”.
Dr Ramchandra Hankare, Pune district health officer, said, “The report has been submitted to the state government. A high-level committee will be appointed to conduct another probe in this case.”
As per officials, in this case, a proposal seeking ₹2 lakh ex gratia compensation under the Union government’s Family Planning Indemnity Scheme has been submitted by the district health officer to the director (finance and accounts), National Health Mission, Mumbai.