Gorakhpur tragedy: Inquiry blames oxygen supply firm, silent on cause of death

An inquiry by the Gorakhpur district administration has held a Lucknow-based firm responsible for disrupting oxygen supply to the Baba Raghav Das Medical College.

The inquiry, into the supply of oxygen to the hospital on August 10 when 23 children died, also alleged that there was "financial anomaly" and overwriting in the log books.

The five-member panel said Dr Satish Kumar, the head of department of anaesthesia, was "prima facie guilty of not discharging his duties". It also named Gajanan Jaiswal, the chief pharmacist, and Dr Rajiv Mishra, the principal of the medical college.

The report was silent on the cause of the deaths and who was responsible.

However, chief medical officer Dr Ravindra Kumar, part of the panel, said that the deaths were not due to lack of oxygen.

"The oxygen supplier firm M/s Pushpa Sale Pvt Ltd, Lucknow had disrupted oxygen supply for which it is responsible, which it should not have done keeping in mind its life-saving job," the committee found.

"Dr Kafeel Khan (nodal of 100-bed AES ward) had said that he had informed in writing about the ward's AC not working to Dr Satish Kumar, but they were not repaired in time. Dr Satish, the HoD of Anaesthesia was absent from the BRD Medical College on August 11 without any written permission."

Stating that he was in-charge of uninterrupted supply of liquid oxygen, it said, "Dr Satish had been prima facie guilty of not discharging his duties."

Pointing to another lacuna, the committee said it was the job of Dr Satish and chief pharmacist Gajanan Jaiswal to maintain the stock book and log book of oxygen cylinders. However, these "were not maintained, and overwriting was done".

"In-charge of logbook Dr Satish did not sign the logbook, which shows that this issue was not taken up seriously either by him or by the principal," the committee added.

According to the report, principal Dr Mishra was out of headquarters on August 10, and Dr Satish had left for Mumbai on August 11 without any permission.

"If both the officials had resolved the problems in time before leaving the medical college, then these circumstances would not had risen. Both the officials must (have) had information about disruption of oxygen supply by the firm."

The committee also said Mishra, given the sensitive nature of the Bal Rog Vibhaag (paediatrics department), allegedly did not pay attention to facilities, maintenance and payments.

"Despite repeated requests being made by the firm supplying liquid oxygen and availability of budget on August 5, and not informing the principal in time and not presenting the patravali (bills), three persons including two from accounts section have been found prima facie guilty," the committee found.

It also recommended an audit and a high level probe by the medical education department.

"Overwriting in the stock book, and non-payment of bills of the liquid oxygen supplier firm either serially or date-wise, prima facie points out to financial anomaly, for which it would be appropriate to conduct an audit and a high-level probe by the medical education department."

CMO Dr Kumar said the five-member committee was constituted to find out whether the deaths on August 10 were actually caused by lack of oxygen.

The inquiry was ordered by Gorakhpur district magistrate on August 11, after the deaths were reported.

Though the report confines itself to the events on August 10, the hospital has been in the spotlight for the deaths of 30 children in a span of 48 hours. Since August 1, 71 persons have died of encephalitis in the state-run Gorakhpur facility.

IMAGE: A child is shifted to another ward at Baba Raghav Das Medical College Hospital in Gorakhpur district. Photograph: PTI Photo