Seven KTH staffers including director suspended

Seven officials of the Khyber Teaching Hospital (KTH) including the medical facility’s director on Monday were suspended after an inquiry report found them negligent in performing their duties, which resulted in the deaths of six Covid-19 patients due to the shortage of oxygen supply.

A day earlier, six Covid-19 patients died at the KTH as the oxygen supply at the medical institution ran out.

Immediately after the incident, the provincial government ordered the hospital's Board of Governors (BoG) to submit a report within 48 hours. However, the preliminary inquiry report was handed over to K-P Chief Minister Mahmood Khan within a day.

While chairing a special meeting at his office on Monday, the K-P chief minister directed the KTH BoG to complete the inquiry within a week and initiate proceedings so that those responsible for the happening could be terminated from jobs and taken to task.

He vowed that the “culprits” would be dealt with an iron hand and noted that if the BoG did not take any action, the K-P government would hold an independent inquiry and proceed against them.

The K-P chief minister announced a sum of Rs1 million each for the relatives of the deceased.

Findings

A preliminary report submitted by the board, headed by chairman inquiry committee Dr Nadeem Khawar, found that the "incident occurred due to system failure" among other negligence.

A total of seven people were suspended for "criminal negligence" that resulted in a delayed supply of oxygen to six patients in Covid isolation ward and ICU of the hospital.

They were identified as KTH director Dr Tahir Nadeem Khan, facility manager Tahir Shahzad, manager supply chain Ali Waqas, biomechanical engineer Bilal Babak, oxygen plant assistant Niamat and oxygen plant duty employees Waheed and Shahzad Akbar.

At the time of the incident, around 90 patients were in the coronavirus isolation ward. Due to the shortage in oxygen supply, the hospital management shifted 13 patients to the Accident and Emergency Department where "limited supply in the form of manifold was available". The rest of the patients were provided oxygen through cylinders, which were in limited supply.

Six patients died due to the shortage in oxygen supply, the report said, while three were initially missing. One is still missing while the other two patients were traced and are alive, according to the report.

The report maintained that none of the two online duty staffers were present at the two plants when the pressure of oxygen decreased. The report findings said the oxygen pressure at the time was zero.

"The rescue squad was found to be incompetent to deal with any unfortunate or unforeseen emergencies within the hospital. While many patients were left gasping for oxygen support, it was found that the duty staff of oxygen plant of the hospital were not present," the report said.

According to the report findings, the services contract between the hospital and a Rawalpindi-based private company M/s Pakistan Oxygen Limited had expired on June 30, 2017.

There was no official order regarding the renewal or extension of the contract in the hospital record and that the supply manager had confirmed the extension of the contract with the oxygen supply company until June 30, 2020 through telephone.

"No office order regarding renewal/extension of contract is available with the record provided by the pharmacy's manager," the report said.

The inquiry committee found that the KTH's oxygen tank had a storage limit of 10,000 cubic metres but the supplier "never filled the tank to the required level".

On December 4, the company only supplied 3,040 cubic metres of oxygen, which was much less than the required capacity of the tank.

It was further noted that there was no backup system for oxygen supply as recommended by the health technical memorandum.

The report stated that no notice was taken of the acute shortage of oxygen in the tank and that the facility manager had not submitted the report on the absence of staff from the plant.

The inquiry committee observed that the supply chain had not timely supplied the required quantity of oxygen, the biomedical engineer failed to perform his duty and the KTH had no emergency rescue squad.

Action

Among other actions taken besides suspending the seven officials of the hospital, the report noted that the committee would further investigate the standards of Pakistan Oxygen Limited's monitoring and supply system.

Moreover, qualified and trained staff will be hired for the oxygen plant, whereas primary and secondary backup system for oxygen supply will also be established on an emergency basis.

K-P Health Minister Taimur Khan Jhagra, in a tweet, appreciated the committee for completing the investigation in 24 hours instead of the stipulated 48 hours.

With the preliminary inquiry report attached in the tweet, he said: "We [are] committed to make the report public. Hospitals across the country may learn from the systemic failures here."

Six Covid-19 patients treated at the KTH in Peshawar passed away on Saturday night after "criminal negligence" resulted in a delayed supply of oxygen to the medical facility.

Hospital spokesperson Farhad Khan confirmed on Sunday that six coronavirus patients, five admitted to the KTH’s Covid-19 ward and one treated at its intensive care unit, died because the medical facility ran out of oxygen supplies.