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The Central Government apppointed a three-member panel of experienced doctors to investigate the deaths of over 70 children at the BRD Medical College in Gorakhpur. Several irregularities were mentioned by the team upon inspection.
The central team comprising of Dr Harish Chellani, a paediatrician at Delhi's Safdarjung Hospital, Dr NK Agarwal, Deputy Commissioner, Immunisation, Health Ministry and Dr Sushma Nangya of Lady Hardinge College.
The panel's report indicated unhygienic surroundings and shortage of trained professionals. Patients are left at the hands of untrained doctors and newborns are left under the care of untrained nurses.
“Currently, there is suboptimal care with regard to asepsis routines (handwashing, use of disinfectants, cleaning of bassinets after discharge or death of neonate), gross overuse of antibiotics and intravenous fluid therapy as well as poor nutritional support in form of enteral feeding… Deaths early after admission (within 12 hours) were just 11%, with 25% within 24 hours of admission and another 25-35% deaths occurring in the next 24 hours. This indicates that nearly 50% deaths are occurring within 48 hours of admission, implying both suboptimal stabilisation at peripheral units and poor care after admission in the BRD Medical College,” report said.
Only 3 out of the 31 nurses working in the neonatal department of BRD Hospital are trained in Facility Based Newborn Care (FNBC).
The report further mentioned, “The overall strength of faculty and junior residents (pursuing MD) including non-academic JR (junior residents) seems reasonable. However, the number of senior residents (post-MD residents) is grossly inadequate being 4 against 12 vacancies and they need to be on the floor to provide 24/7 cover and not just during routine hours. It is these post-MD senior residents who take decisive actions as regards patient care and make a significant difference to the quality of care provided to patients."
Upon inspecting the statistics of deaths, the panel said, “Deaths early after admission (within 12 hours) were just 11%, with 25% within 24 hours of admission and another 25-35% deaths occurring in the next 24 hours. This indicates that nearly 50% deaths are occurring within 48 hours of admission, implying both suboptimal stabilisation at peripheral units and poor care after admission in the BRD Medical College.”
Indian Medical Association (IMA) on August 17 said that the fact-finding team of BRD medical school had found that the oxygen supply in BRD Hospital was interrupted for a short while on the night of August 10 which lead to more deaths.
IMA further added that the dues for liquid oxygen supply has been pending for the last five months and cleanliness of the hospital was also unsatisfactory.
IMA team said, "Presence of dogs and rats in hospitals is not acceptable by any standards in the hospital premises. The hospital was handling these cases and other critically ill patients much more than its capacity. There is no facility in Gorakhpur and nearby districts to manage encephaliti."
According to the IMA, doctors on duty should have been alerted seven days before shortage of oxygen supply by the hospital administration.