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

Written by savita thakur thakur Published On 2017-09-02T09:32:29+05:30 | Updated On 2 Sept 2017 9:32 AM IST

New Delhi: The Delhi Medical Council has said that "administrative lapses" led to the deaths of five patients at a trauma centre here in 2012, and recommended that the city government initiate "corrective measures" to prevent a repeat of such incidents.

The council, in a statement, said, it has examined a case referred to it by the Delhi Police in connection with deaths of the patients at the Sushrut Trauma Centre due to "disruption in oxygen supply" at the intensive care unit (ICU).

It has observed that "on the intervening night of December 4 and 5 in 2012, only one employee was posted on duty in the manifold room instead of two technical personnel, which is recommended".

"Untrained person said to be technicians were employed by the company to provide oxygen to the ICU at the trauma centre and the annual maintenance contract (AMC) of the pipeline was not renewed timely," the council said.

The medical body also pointed towards the shortage of nursing staff on the night of the incident for managing "five critically patients on ventilator".

It said the doctors and nursing staff performed their duty with proper care.

"In this case there was no medical negligence on the part of doctors, but unfortunately lives were lost, due to administrative lapses, hence the government of Delhi is requested to fix accountability and initiate corrective measures, to prevent such incidents from happening in future," the council said in the statement.

The Sushrut Trauma Centre was established in 1998 for providing critical care management to trauma victims, including for head injury, as an annexe of the Loknayak Hospital under the overall administrative and financial control of the medical superintendent of the LNJP.

Here are the issues pointed by the 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.

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