Wednesday, December 27, 2000,
Chandigarh, India


M A I N   N E W S

Scalpel falls on surgeon
Khanauri tubectomy deaths

From Sushil Goyal
Tribune News Service

SANGRUR, Dec 26 The three-member fact-finding committee of the PCMSA has held Dr S.S. Joshi, SMO, Moonak, who performed the operations responsible for the Khanauri tubectomy tragedy in which two women died within two to three days of the operation while nine women suffered serious health problems which led to their admission to the local Civil Hospital. Seven of them were later shifted to Rajindra Hospital, Patiala. These 11 women were operated upon for tubectomy on December 4 at Khanauri Mini-Primary Health Centre (PHC).

The fact-finding committee was constituted by the PCMSA on December 8. It was headed by Dr Darshan Pal, district president of the PCMSA, while Dr Ravinder Klair and Dr Sanjiv Jindal, both surgeons, were the other members.

Dr Surinder Singla, regional secretary of the PCMSA, said here today that the report of the committee had been sent to the state president of the PCMSA, Dr Baldev Sahota.

The committee has fixed the entire responsibility of the Khanauri tubectomy tragedy on Dr Joshi. It has also not spared the other members of the operating team from responsibility. The committee has added that besides violations in the implementation of the rules before and after the operations, the medical aid, given to the women patients by Mr Des Raj, medical practitioner, and negligence on his part, had become the immediate cause for the death of two women Reshma of Banarsi village and Sheela or Therri village.

On the basis of inquiries and talks and interviews with the members of the bereaved families, members of the staff of Khanauri and Sangrur hospitals, and the women patients, the committee has gathered some points which show negligence and irregularities allegedly committed by the operating staff.

The committee has reported that no blood and urine tests of women were conducted before the tubectomy. Also no gynaecological or medical check-up was made. Equipment used in the operations was also not properly sterilised because there are two sets of equipment at the Khanauri mini PHC for tubectomy operations and each set requires about 20 minutes for sterilisation. But in this case, all women were operated upon in one-and-a-half hours. It shows that equipment was not sterilised properly.

The committee has also mentioned that the surgeon had used only one set of gloves for operating upon all 11 women whereas the surgeon has to use a fresh sterilised set of gloves after every operation. All women after operations were shifted to their respective villages in two hours in jeeps while it is mandatory in stomach operation cases to have a patient in the hospital for at least 48 hours to 72 hours. The women were also given medicines like tetracycline which are considered ineffective in operation cases to prevent infection and dry the wounds.

The committee has concluded that all women were infected during operations in the Khanauri mini PHC as the operating team did not follow the surgical rules meant for preventing infection, before, during and after operations.

The committee has also held Roseleen, ANM at Khanauri mini PHC, and her husband Dev Raj, a medical practitioner, guilty on account of negligence in providing medicines and injections to the patients without the consultation of the doctors concerned.

The committee has also raised questions over the post-mortem of Reshma under Section 174 of the IPC on December 7 though she died on December 5. The post-mortem of the other woman, Sheela, who died on December 7, was not conducted. The committee has claimed that these actions create suspicion about the authorities using their influence in both these cases.

The committee has also suggested some measures to prevent such occurrences in the future. They include stopping family planning camps where staff shortage prevails in the health centres, compulsory gynaecological and medical check-up besides testing of blood and urine before operations for tubectomy, introduction of AIDS and hepatitis-B tests before operation, uninterrupted power supply to the operation theatre, not more than 25 family planning operations in a camp, and sterilisation of equipment as per the surgical norms.

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