NE NEWS SERVICE
GANDHINAGAR, SEP 28
Reports of an inquiry commission that probed fire incidents at two hospitals in Gujarat were tabled in the state legislative Assembly on the last day of the Monsoon Session on Tuesday.
Inquiry reports of the Justice (Retd) D A Mehta Commission, which was constituted to probe fire incidents in which 13 COVID-19 patients died in 2020, have pointed out several lacunas.
Apart from the inquiry reports, the state government also presented the Action Taken Report on the floor of the House.
The fires took place in Shrey Hospital in Ahmedabad’s Navrangpura area on August 6 last year, in which eight COVID-19 patients died, and Uday Shivanand COVID-19 Hospital in Rajkot in November that saw the deaths of five patients.
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The report stated that the fire at Shrey Hospital was a result of a short circuit in a “patient monitor”, while the blaze at Uday Shivanand Hospital was caused by a short circuit in the “thermo sensor” on a tube that supplies oxygen to patients from a ventilator.
Although the effective working life of a monitor is around five years, monitors at Shrey Hospital had been in use for over 15 years, the report revealed.
The Commission noted that the “management of Shrey Hospital in Ahmedabad has to be held responsible for the fire for having continued to use patient monitors, which had been rendered obsolete, as they were purchased way back in 2003-2004. Merely having them serviced would not absolve the management”.
Using a medical equipment for a period of more than 15 years, which is 3 times the normal effective life of such equipment, is an invitation for disaster, the report added.
Moreover, there was no emergency exit at Shrey Hospital to rescue the patients, and firefighting equipment were not in adequate numbers inside the ICU ward, the report said.
The Commission also took a strong view about the government’s policy for the regularisation of unauthorised construction by charging an impact fee.
Apart from deficit parking space, the Commission found “various violations” regarding the construction.
“If unauthorised construction in and on the premises of Shrey Hospital would not have been regularised, the fatalities could have been avoided,” the report said.
Apart from these violations, the Commission also pointed out the lack of ventilation in the ICU ward of the hospital.
Since there were obstructions in the margin area, the fire brigade was forced to go on the terrace to access the ICU on the fourth floor, which was gutted in fire, killing eight COVID-19 patients, it stated.
This resulted in a delay, which caused seven out of eight patients to die of asphyxiation, while one patient died of burn injuries, the Commission report said.
In case of the fire at Rajkot hospital, the Commission noted that the hospital had installed ventilators of “Dhaman” brand in the ICU.
The blaze was caused by a short-circuit in “thermo sensor” placed on a tube, which supplies oxygen to the patient from a ventilator, it said.
The Commission did not specifically blame the ventilator manufacturer for the accident.
The hospital management claimed that these ventilators were not purchased and were only “brought from the company for the purpose of using”.
“The management of the hospital, having not purchased the ventilators, would not be in a position to take any action against the manufacturer, even if a particular piece was found to be defective or of sub-standard quality,” the Commission said.
The report further pointed out that the emergency exit door was closed and blocked, as the management had put medical equipment across the door.
In a scathing remark, the Commission stated that “before making any recommendations, it is necessary to take note of the fact that there are major serious deficiencies/defects in so far as the functioning of the state government is concerned”.
In view of both the incidents, the Commission made several recommendations to the government, such as giving up the policy of hiring fire personnel through outsourcing to improve performance, revisiting the policy of regularisation of unauthorised construction and compulsory registration of every nursing home each year.
For better monitoring, the Commission also asked the government to bring all clinics and hospitals under one legislation and under one department.
Meanwhile, the state government in its Action Taken Report agreed to “act for the registration of all nursing homes”.
The government also stated that Clinical Establishment Act, which brings all clinics and hospitals under one legislation, has already been passed and notified recently.
The state government accepted the Commission’s recommendation that hospitals must have two staircases for emergency exit, and said that it will implement the same while issuing fire NOCs to new hospitals.
The state government further assured that fire NOCs will not be given to hospitals that have false ceilings, as it leaves less space and traps the smoke at eye level, which happened at both hospitals.
The state government said that a long-term policy will be made to train hospital staff in firefighting.
The Commission recommended that the government should frame a policy to phase out medical equipment and ventilators after five years of service.
To this, the state government, in the ATR, said it will “examine this recommendation further”.
