Khyber Teaching Hospital’s Board of Governors (BoG) has submitted its initial investigation report on the oxygen shortage at the hospital that resulted in the deaths of six patients.
Special Assistant to the KP CM on Information Kamran Bangash tweeted a copy of the report saying a high-level meeting to be chaired by Chief Minister Mahmood Khan today will review it and take further decisions in this regard.
According to the report, seven officers, including the Medical Training Institute (MTI) hospital director Dr Tahir Nadeem Khan, have been put under suspension.
It said five of the patients who died due to lack of oxygen supply were in the Covid-19 ward while one was in the ICU.
The MTI has an oxygen storage tank of 10,000 cubic meter capacity but there is no backup system for oxygen supply as recommended by the health technical memorandum (HTM), the report found, noting: “Ideally there should be either a primary back (another tank) or secondary backup (Manifold).”
It revealed that the hospital had given a contract to Ms Pakistan Oxygen Limited, which expired on June 30, 2017 and no renewal/extension of contract is available in the record provided by the manager pharmacy. The supply chain manager confirmed the extension telephonically till June 30, 2020.
The hospital oxygen tank was last filled on December 4 by 3,040 cubic meters and has never been filled to the required level, the report disclosed.
Besides, the inquiry found that the staff at the oxygen plant lack proper technical skills and training.
The report said the on duty manager of services received a call from the main operation theatre regarding low oxygen pressure. He called the oxygen plant operator but he was not picking up. He then physically visited the plant and found out that the two on duty staff members were not present. “The pressure in the oxygen plant at that time was recorded zero as per the Pressure gauge reading. The Oxygen plant Assistant Mr. Naimat failed to perform his duty as he is responsible for the oxygen plant and has a liason with the supplier. ”
At the time of the incident, the report said 90 patients were in the isolation ward, 20 of them were on BiPAP, two on ventilators and the remaining on mask oxygen. Due to the depletion of oxygen in the central tank, the patients’ lives were at risk. The administration ordered that 13 of them be shifted to the accident and emergency department where backup supply in the form of manifold was available and the remaining patients were put on cylinder oxygen.
There was no organized emergency rescue squad at the hospital as required for disaster management under such conditions.
“Six patients in the isolation ward expired. Three patients were missing, one is still untraceable and the other two were traced and are alive.”
