Sushrut Trauma centre case: Administrative lapses, not medical negligence led to deaths says Delhi Medical Council

• Untrained person said to be technicians were employed by the company to provide a continuous supply of oxygen to the ICU at Sushrut Trauma Centre. On the night intervening 32 and 4^. December, 2012 only one employee was posted instead of two trained employees, as per


• During night shift only one person was posted on duty in the manifold room instead of the recommend two technical personnel.


• The Annual Maintenance Contract of the pipeline was not renewed timely.


• Only one staff nurse was on duty on a fateful night in ICU for managing five critically patients on the ventilator, which is not in accordance with the prescribed nurse / patient ratio in ICU. Despite this the doctors on duty and nurses resuscitated all the five patients.


• Disruption of the oxygen supply was lapse on the part of the company, who was responsible to provide the continuous supply of oxygen. After which two doctors along-with nursing staff called other doctors and nurses from operation theatre etc and managed/resuscitated all the patients and performed their duties with proper care and skill. All the Otis patients in question were on ventilators and critically ill, suffering from neurosurgical problems with poor

"In future, any disruption in the supply of oxygen and such failure should be brought to the notice of the competent authority by the person who is responsible to use the equipment for further rectification of the defect," it added.