Corpse on patient’s bed in Ludhiana: Civil Surgeon recommends action against SMO, EMO for ‘negligence’, ‘insensitivity’

Tribune News Service

Nitin Jain

Ludhiana, April 17

The Civil Surgeon, Dr Jasbir Singh Aulakh, has recommended action against the Senior Medical Officer (SMO) in-charge, Dr Mandeep Kaur Sidhu, and the Emergency Medical Officer (EMO), Dr Manju Nahar, of Lord Mahavira Civil Hospital, here.

The action has been sought after both senior doctors were indicted for “administrative negligence” and “insensitivity” in a prima facie inquiry conducted by Dr Aulakh on the order of Deputy Commissioner (DC) Sakshi Sawhney.

The DC had taken a suo motu cognisance of the media reports, wherein it was highlighted that a patient’s corpse was kept on the same bed where another alive patient was lying at the emergency ward of the Civil Hospital here on April 14.

Patient’s hospital admission history

• April 9 at 8:40 am: Patient admitted to emergency ward of Civil Hospital
• April 9: No doctor’s signature on admission slip or notes on patient’s file
• April 9: Without any consultation or examination on record, the patient was diagnosed fracture/femur/COPD etc on preliminary admission notes
• April 10, 11: No general duty or specialist doctor examined patient
• April 12 at 9:20 am: Note written on file, “Patient is not on bed”
• April 13 at 9 am: A doctor wrote on the patient’s file, but without signature
• April 14 at 8:05 am: A doctor noted the patient’s blood pressure, heart rate and SPO2 and called for anaesthetist and medicine specialist, but again no signature on file
• April 14 at 8:20 am: A resident doctor of the Anaesthesia Department examined patient
• April 14 at 9 am: A resident doctor of the Medicine Department referred patient
• April 14 at 11: 40 am: Patient died as no specialist or consultant anaesthetist or medicine specialist or consultant examined him
• April 15: Civil Surgeon calls SMO for preliminary report wherein SMO informs verbally that corpse kept lying with another alive patient on the same bed from 11:40 am to 1: 40 pm for two hours
• April 15: However, in a written preliminary inquiry report, the SMO mentioned that the corpse kept lying on the same bed with the patient alive for 37 minutes only
• April 15: DC orders Civil Surgeon to conduct an inquiry, who submits report the same day, recommending action against the SMO and the EMO.
• April 15: DC forwards report to the Health Secretary and issues SOP for all hospitals and health centres

Taking note of the prima facie report, the DC has forwarded it to the Health Secretary for further action and issued a standard operating procedure (SOP) for dealing with heavy rush and proper patient handling at all government hospitals and health centres in the district.

“It may be ensured for future that such an incident is not repeated in any hospital or health centre,” the DC told the Civil Surgeon, while instructing that there must be proper sensitisation of health staff and even in case of heavy rush, doctor on round should ensure appropriate arrangements for patient handling.

Sakshi told the Civil Surgeon to follow SOP, especially for dealing with cases where patient inflow was in excess of available beds.

In a two-page inquiry report submitted to the DC, a copy of which is with The Tribune, the Civil Surgeon concluded that no specialist or consultant anaesthetist or medicine specialist or consultant examined the patient during his stay in the emergency ward of the Civil Hospital for six days following which his condition kept deteriorating and he died at 11:40 am on April 14.

“From the above facts, the undersigned has reached a conclusion that this all was result of the administrative negligence on part of Civil Hospital SMO in-charge Dr Mandeep Kaur Sidhu, who according to records was never on round of wards between April 9 and 14,” the Civil Surgeon reported.

Dr Aulakh also indicted EMO Dr Manju Nahar for “insensitivity” in the case.

“If in any case, two patients are forced to share a single bed, at least an alive patient should have been shifted to another bed when the condition of another patient, with whom he was sharing the bed, had turned serious and he later died so that an alive patient could have been saved from the mental trauma that he faced while sharing bed with the corpse,” he observed, while stating that it proved the insensitivity of EMO Dr Manju Nahar, who was on duty.

Picking holes in contradictory statements given by the SMO in the case, the Civil Surgeon reported that on being called by him on April 15 to seek preliminary report in the case, SMO Dr Mandeep Kaur Sidhu brought along EMO Dr Manju Nahar, staff nurse and a Class IV employee to his office to inform him verbally that the patient had died at 11:40 am and was shifted to the mortuary at 1:40 pm on April 14, which proved that the corpse kept lying in the emergency ward for two hours.

The same information was shared by Dr Aulakh with the DC and the Director, Health and Family Welfare, through WhatsApp messages.

However, in a written preliminary inquiry report submitted by the SMO to the Civil Surgeon, it was mentioned that the corpse was shifted to the mortuary at 12:17 pm on April 14.

In his prima facie report, the Civil Surgeon also brought on record that neither on the admission slip nor on notes made on the patient’s file, there were any signature of any doctor nor was any date mentioned.

Moreover, Dr Aulakh reported that following admission of the patient at 8:40 am on April 9, some X-rays, CT scan of head, and some other clinical tests were advised on the file, which were never conducted.

“On the preliminary admission notes, the patient was advised orthopaedic consultation, which was never done, while on his referral slip, fracture/femur/ COPD etc were mentioned,” the inquiry report stated.

The Civil Surgeon further reported that no general duty or specialist doctor examined the patient till April 11 while on April 12, it was mentioned on his file that the “patient was not on bed”. “Surprisingly, how can the patient with femur fracture and in serious condition move from his bed?” he questioned.

The inquiry report submitted that some doctor put a note on the patient’s file at 9 am on April 12, but without any signature. Similarly, on April 14 at 8:05 am, the blood pressure, heart rate and other readings of the patient were noted on his file while calling for the anaesthetist and medicine specialist, but again no signature of the doctor, who wrote that note, was on the file.

It mentioned that on April 14 at 8:20 am, the patient was examined by a resident doctor of the Anaesthesia Department and at 9 am, a resident doctor of the Medicine Department, made a referral slip of the patient.

“No specialist or consultant anaesthetist or medicine specialist or consultant examined the patient, following which his condition kept deteriorating and he died at 11:40 am,” the Civil Surgeon concluded.

Civil Surgeon asks SMO to Submit footage of cctv cameras

Civil Surgeon Dr Jasbir Singh Aulakh has asked Senior Medical Officer in-charge of Lord Mahavira Civil Hospital Dr Mandeep Kaur Sidhu to submit CCTV camera footage and record of her rounds in hospital wards from April 1 to 15.

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