Independent Investigation Report of Gross Violations of Cataract Surgery Camp, jointly organized by Barwani District Hospital and Lions’ Club
Representatives of Jan Swasthya Abhiyan and Narmada Bachao Andolan
15th December 2015
An independent investigation was carried out by representative of Jan Swasthya Abhiyan, Narmada Bachao Andolan and Swasthya Adhikar Manch into the serious matter of a large number of patients losing their eye sights as a result of an eye cataract surgery camp which was jointly organized by Barwani District Hospital and Lion’s Club between 16th to 24thNovember, 2015, under the District Blindness Control Programme, part of National Blindness Control Programme. A committee is formed under the District Blindness Control Programme which is chaired by the District Collector. This committee allocates budget to NGO-s for the camp and procures drugs, injections, and other necessary items through state level tender, or local tender or direct purchase under the guidelines set by the Government.
A total of 86 patients from Sendhwa, Silawad, Dhanora, Warla, Chachria, Balwadi, Pansemal, Niwali, Piplaj, Ekkalwara, Kashta, and Dharamrai of Barwani and Dhar district of Madhya Pradesh were operated upon in the camp.
Ringer’s Lactate solution was used during surgeries which is usually packaged in plastic bottles and have probability to catch fungus. The particulars and quantity of which pre-operative medicines, intra-operative medicines, and post operative medicines were used is not known. Moreover, it is a matter of severe concern whether these medicines were procured through State level tender or local tender or through direct purchase.
After the operations, at the time of discharge, the patients were advised to visit their nearest health centre for follow-up. Based on findings and interviews with patients and their relatives, it is known that the patients were prescribed Moxicip Eye Drop (Moxifloxacin), batch number C850127 of Cipla, Zoxan D of FDC Ltd, Atropine Sulphate of Jawa Pharmacy, Biotin, Levofloxacin and Ibuprofen at discharge. The question is where these medicines were sourced from – centrally from Bhopal or locally at Barwani.
On the 2nd-3rd day after the surgery, patients went to health centers/or to the district hospital with complaints of burning sensation and pain in the eyes.
They were given injections and some medicines and were asked to return for follow-up. Some patients went to private hospitals and spent from their pockets for follow-ups as the district hospital was far. The patients got no relief from their symptoms.
By 18th-19th December, similar multiple complaints of pain, itching and watering eyes had started pouring in from the first batch of patients; despite that, surgeries of new patients were continued. It is beyond comprehension as to why fresh surgeries were continued even after knowing that things were amiss and earlier patients had caught severe infections.
When the complaints became acute and widespread, most patients were asked to come to the District Hospital where they were admitted for follow-up treatment. But none of the patients got any relief from this treatment. Some of the patients were taken to a private hospital namely to Dr. Rajendra Malviya of Sarswati Eye Hospital. As per interviews with patients, it came to light that the letterhead portion of the prescription of Dr. Malviya was torn off and the rest of the prescription was filed in the hospital file. The investigators are in possession of sample copies of Dr. Malviya’s prescriptions and the same is attached with this report.
Following this, most of the patients were referred to Sri Aurobindo Institute of Medical Science (SAIMS), Indore. Some patients were referred to M.Y.H. Hospital, Indore where they were kept for a day, followed by moving them to SAIMS. It is questionable as to why patients were referred to SAIMS instead of being treated at M.G.M. Medical College attached hospitals despite MYH Hospital having adequate numbers of ophthalmologist specialists of all levels.
According to Govt. rules, in case of emergency, patients should be referred from the District Hospital to M.Y.H. Hospital attached to M.G.M Medical College. It is clear from the patient case documents that they were referred to M.Y.H. Hospital. But what is completely unclear is on what basis and on whose orders were they sent to SAIMS. It is mentionable that SAIMS have been in the mid of controversy earlier. Around 3 years back, the State Govt. had attempted privatization and wanted to shift M.Y.H. Hospital to SAIMS under PPP model, in the guise of knowledge partnership. At that time, this was stopped by sustained campaigns and collective effort of organizations, individuals, medical fraternity and media.
It’s not clear despite sending to a private setup, how many patients could save their eye sight fully or partially.
At the time of referral to Indore, only few patients had lost their eye sights. After getting admitted to SAIMS, the patients underwent repeated eye surgeries. During the period the patients were in the district hospital or later admitted to SAIMS, out of 86 patients, 66 patients have lost sight of one eye completely. The condition of the remaining 20 patients needs to be made public. The Govt. investigation team should publish complete list of all 86 patients including their particulars, detailed condition, whether any of them have recovered their sight, how much has been spent on each patient by hospital management.
The first referral to Indore occurred on 3rd December, 2015 whereas infections were reported by 18th-19th November, 2015 timeframe. What was the cause for waiting for such a long time after the infections were confirmed? There is no clarity on how infections erupted even today after almost one month has passed since the camp.
The Government investigation team has not yet disclosed batch numbers, quality test reports, company names, and procurement detail of drugs, injections and fluids used. These should be made available to the public immediately. The Companies from where drugs were procured and beneficiaries of these companies or people who stand to profit from of these companies should be disclosed.
The issue of supply of sub standard drugs throughout the State was raised earlier, but government has not taken the matter seriously.
Case Study of Rashid Khan, son of Kaasam Khan
Rashid Khan came to the District Hospital of Barwani on 14th November,2015 for the treatment of his eye. On the same day at 6 pm, he underwent cataract operation. He was discharged on 15th Novemeber, 2015 from the hospital. Around 8 days later, he complained of severe discomfort in his eye. He came back to the hospital on 24th Nov and was sent back home after giving treatment. However, he got no relief. He went to Dr. Malviya of Saraswati Hospital on 28th Nov and spent Rs. 200 on fee and Rs. 1400 on medicines. His bills are available. He got no respite from the pain and itching in his eye. He was sent to SAIMS Indore on 3rd December, 2015. Rashid Khan has now lost sight of his eye.
Case Study of Nania
Nania, son of Junga, from Village Kashta, Dharamrai, Nisarpur Block, Dhar went to the house of Dr. Radhesham Palod on 18th Nov, 2015 for treatment of his eye. He paid a fee of Rs. 200 fees and Rs. 2500 for cataract operation. His surgery was carried out the next day at the eye camp in the District Hospital. After the operation, he was discharged the next day. He started getting pain and burning in his eyes. He came back to the district hospital on 28th November and saw Dr. Malviya on 29th November. His symptoms did not change at all and he got no relief. He was sent to SAIMS on 6th December. Nania has lost sight of his eye.
Major findings of the investigation
· It is clear that infections had spread from the site of surgery and equipment used during surgery.
· Quality of drugs, fluids and injections used on the patients during and post surgery are questionable.
· Hygiene of operation theatre was compromised. This is noted in the whole hospital in all wards and complaints were made by various organizations earlier. It needs to be enquired whether separate sets of gloves, instruments and materials were used for each patient.
· Proper process of follow-up by doctors/medical team/hospitals was not done, such as centralized and timely checkup in the district hospital.
· Timely identification and treatment of infection did not happen.
· That it was carelessness and casual approach of the eye surgeons and support staff as well as from CMHO and Collector that led to continuation of operation without action even after the first batch of patients returned with various complaints and infections.
1. Patients should be treated at the higher level and their eyes should be replaced without delay. If required, they should be immediately sent to higher referral hospitals outside the State.
2. Patients, who have definitively lost their eye sights, must get due compensation. Victims, who were earning members of families, should receive higher compensation. Non-earning members should receive regular pensions.
3. State should issue order for high level independent enquiry into the whole matter. Enquiry should cover all drugs, fluids, equipment, and medical process.
4. There should be enquiry into the procurement process of all medicines, injections, saline and other relevant products and items.
5. Strict action should be taken against the offending doctors/medical officers/collector/and others involved in the camp. Suspensions of Collector, CMHO and nodal officers of National Blindness Control Programme are demanded with immediate effect. In the course of events, one can see the tendency of putting all blame on a single doctor, whereas all concerned State and District health and administrative officials should be investigated and due criminal action taken.
6. At least one member of each affected household should be provided means of regular livelihood. Free Medical facilities should be provided to all affected families.
· Signed complaints from patients
· Sample Hospital documents of patients
· Memorandum given by JSA, NBA and SAM
Investigation done by:
Rakesh Chandore, Dhara, Amulya Nidhi, S.R Azad – Jan Swasthya Abhiyan
Medha Patkar, Devisingh Tomar, Bhagirath Dhangar, Rahul Yadav – Narmada Bachao Andolan
Contact : 9425311547, 9818111755