Death at CRH’s doorstep – Who’s to be held accountable?

By Pankaj Dhungel A video of a young girl crying and addressing on the lapse of time and no help from the Central Referral Hospital resulting in the death of her father went viral on social media around 9:30 pm on Tuesday night.

Death at CRH’s doorstep – Who’s to be held accountable?

She states in the video, “Our father was brought in this vehicle around 7-7:30 pm. We requested to the sisters (nurses), knocked on the doors, called people to help. Only after that, he was helped, there was a lot of carelessness, despite so much request, they didn’t listen”, before her cries drowned out the rest of her words.

Another young girl in attendance narrated, showing the vehicle they had arrived in, “We came in this vehicle from Namchi, we were referred to Gangtok, to Manipal Hospital, it was an hour to even one and half hour of time, we requested so many doctors, neither the sisters listened. Her Papa expired in the vehicle, hurriedly we were trying to wake him up, the doctor then checked the pulse, took him inside, then they declared the patient is no more”

The Incident

The incident rattled Sikkim, as outward public opinion was drawn of ‘negligence by CRH Manipal’. The Hospital was left red-faced, as it was the third case of ‘negligent death’ at the medical institution in less than a week. The incident was heart-wrenching, as it unfolded right at its doors.

The deceased had suffered an injury to the head following a fall from his bed at their home on Tuesday morning, and a brain haemorrhage was suspected. The patient, a 42-year-old father lost his life, stretched in a taxi vehicle, as his young daughter was left wailing for help, till his last breath.

By 10 pm another video went viral – the public at the hospital along with others who had reached the emergency ward began addressing the concern to the CRH staff inside the Emergency Ward. This citizen outcry sent shock waves across the state and Manipal Hospital was left to answer on their carelessness.

The hospital carried out a media address at 11:30 am on Wednesday, led by Dr Mingma Lhamu Sherpa, Assistant Medical Superintendent along with others as part of Head of Operations at the Hospital. They maintained that the patient arrived without any medical support in a Tata Sumo (Taxi) around 7:10 pm when sanitization of the Emergency premises was taking place, post 2 RAT positive case detection at the Triage in Emergency of CRH. “A doctor was attending to the patient in the car itself. Thereafter, the patient was declared dead in the Emergency ward, CRH”.

CRH Manipal’s Failure

What fails to be addressed was the hour the young daughter spent crying at the door of the emergency ward, asking for help. The family claims that Manipal opened its door around 8:30 pm but the hospital management claims they attended to the patient around 8:20 pm. Yet, public outcry reads that 2 hours were spent in vain before the patient could be attended. The general stand is also that of 2 COVID-19 positive cases were recorded in the Emergency ward, mere hours before.

In the media address, Dr Sherpa stated, “The patient was initially taken to Namchi District Hospital around 9:30 am on Tuesday as indicated in the referral slip, with an incident of fall reportedly of having happened early in the morning as per the patient party. From where he was referred to STNM/CRH for further evaluation and management. The first access to health care was in Namchi, the patient was brought in a taxi, with as per our knowledge, there was no medical support in the vehicle. We are not passing the concern to Namchi, but we are stating facts because we cannot go as per assumptions”.

The barrage of question from the media ranged from ‘why were the doors not opened when the daughter was knocking time and again?’ ‘If the emergency ward was sealed why was there no alternative ward or space to attend emergency cases?’ ‘If it was done on time, could the patient not be saved?’

CRH Manipal’s statement

The issue then reached to the examination of surveillance camera footage of the time of arrival by the Sikkim Police. While the hospital maintained two hours to be an assumption from the patient party’s version of the public address.

CRH’s press release

“We have to examine the timing first, but also need to understand that the doctor on duty was attending to the patients who turned COVID positive hours ago. He too was exposed. It was not the same doctor who was supposed to go for treatment. We will establish the facts and get back to you with a statement again.

There are so many questions going, there is a legal framework, to a person who turns dead in emergency ward. There is no end to speculations, we are also a very responsible hospital. We will talk on facts not on assumption and presumption, we do not want to appear irresponsible. There is a postmortem finding, that will exert on the cause of death”.

Last Month, Manipal was declared to handle all non-COVID-19 related cases, away from STNM Hospital. “We have to handle all critical head injuries along with all other cases, this case is unfortunate, and we have constituted a committee with forensic expert, where two are from CRH and one is from STNM Hospital. The CCTV will be investigated by Sikkim Police. Police have to give permission for forensic examination, for which we have an independent examination from STNM forensic expert”.

Will action be taken?

The Hospital shied away from taking any punitive action against its staff until the investigating committee finds facts. “It could be the doctor, nurses, or technician. Negligence perceived and the actual negligence will have a lot of difference, even under the legal framework. It will be an action from the legal framework. It is unfair on the healthcare personnel, who have given extra time, energy and care towards patient care within limited resources and a lot of challenges.

Challenges are not only Manipal, Government of Sikkim or Sikkim per se, but it is also worldwide. Yes, our staffs are overworked, we are also facing the dynamicity of the emerging pandemic. But that does not mean we have willingly or knowingly let to lack of care for patients. As per the police proceedings, the investigation report will be submitted. When it is medical/legal, the police is involved”, stated Sherpa.

On the repeated allegation of negligence by the Hospital, Manipal maintained, “Hospital faces with mortality, Hospital is where people come with complications. 100% success no hospital can give. We will report and issue in a press release. We will work out on the timeline of the incident that occurred and present a report on the investigation. We are changing the way we address such issues”.

The deceased’s daughter demands justice

The young girl in contention, who lost her father, speaking with media following the Hospital Management’s address, demanded justice. “I have not placed any other demand. The doctors didn’t come, we went inside and called the doctor. It was around 8:30 pm. No one else had come since 7 pm. They checked his pulse, he was dead. When he was brought from Namchi, he was still okay. He was still breathing.

We requested the doctors in Namchi for ambulances for hours, called the ambulance numbers, went to the office of the Medical Superintendent and requested for ambulance, he responded with there being no ambulance. Hence, we had to privately look for an ambulance and bring my father. I was hopeful that my father would live, had he been treated. He was breathing, he had not died on the way. There was public outside the Manipal emergency, they requested the doctors saying the patient is about to die, only then they came to treat”.

A family member of the deceased, requesting anonymity also questioned if Namchi should have provided ambulance. “The patient was admitted to the Namchi District Hospital around 9:30 am and it appears they ran a number of tests, before sending him here. Now when they refer they must provide for an ambulance, the same was seen lacking. It’s the hours spent at Namchi District Hospital that is also in question. They had to look for an ambulance and the same could not be provided, they spent hours on it. The vehicle they brought was devoid of medical support, a taxi that they hired. It is true the negligence has happened and maybe my uncle could have been saved. It is negligence not just on the part of Manipal but District Hospital as well. As it is known fact, that District Hospitals are in shortage of ambulances amid COVID”.

Namchi District Hospital’s stand on referral

Namchi District Hospital’s Medical Superintendent, Dr SN Adhikari maintained, “The patient had a history of loss of consciousness and when he was brought to Namchi District Hospital, the patient was unconscious. All procedures, including CT scan for the brain when conducted, it showed subdural haemorrhage, which is brain haemorrhage being detected. Following which we referred, as brain haemorrhage cannot be treated in a district hospital. The patient was in serious and critical condition. Hence, the diagnosis of CT scan asserted on referral”.

His wound was not visible, to which the DMS maintained, “When we say brain haemorrhage, it does not have to be due to some impact, as in the case of the patient falling from his bed. It could be a case of blood vessels rupturing as he is a patient with hypertension, he was not diabetic.

CRH
death
Referral Document form Namchi – I
Referral Document form Namchi – II

Even in our report, there is no mention of him falling. He mentioned that he was had a headache since a day ago. He suddenly was left unconscious, there was no mention of when it happened. The patient had reached on 9:20 am on Tuesday, there was no high pressure detected, all tests were conducted. CT Scan took time, after which an MD or a Medical Specialist has seen, injections have been given. When the Scan revealed that it was haemorrhage, we did not conduct the ECG of the patient. Focus shifted to haemorrhage, needing ICU care, with haemorrhage, being handled only by Manipal”.

The patient was referred at around 4: 30 pm and admitted the DMS Adhikari. “We admit the time taken was long, as it was an elaborate investigation, blood test, Kidney Function Test, as a result, will take 2-3 hours. The treatment took time, there were drips being given, blood taken, reports would take time, sugar test was immediate. After the CT Scan we referred, it took time as per the report. District Hospital lack in many equipment with dependency on the private sector. Until all reports are collected, we cannot refer”.

On the lack of ambulance, the DMS maintained, “We have three ambulances, two of which have been devoted to COVID, so we cannot take a non COVI patient. It will be a public issue and there will be a public outcry. We had one other ambulance, that too had gone to Gangtok. Hence, we couldn’t give ambulance, and them finding a private vehicle might have taken time. The daughter had come to me for an ambulance and I explained to her. We have some vehicles kept for an emergency, gave her the phone numbers to make the call. A driver of the ambulance, tried to help on grounds of his friends being in reach. The vehicle lacking was an issue for them to reach on time”.

It took three hours to reach Gangtok from Namchi.”The chances of surviving a brain haemorrhage are through immediate operation and taking out the blood clot that may have developed. There are different kinds of a brain haemorrhage. We cant assert on one variable. Within 4-6 hours, the patient can survive but there is no 100%. If it outside of the brain and if the cranium is operated, then there could be a chance. But internal bleeding, chances are less. It is not possible in District Hospital, it needs a Neuro Surgeon with Manipal being the only alternative, not even STNM”.
It is not a case of shortage of staff maintained the District Hospital, but of lack of facility to counter such cases.

“If we would have sent the patient, 4-5 hours then also the patient had minimal chances of survival. Haemorrhage has less chances of survival. ICU care was the main reason we had referred, without which there was nothing we could do to an unconscious patient. His history maintains, that the patient was suffering from the issue from a day prior, his headache might have begun then. If he could have reached Manipal on time, may be he could have been saved. His bleeding might have begun a day prior, 24 hours later it is a lot of bleeding. Mere hours after the incident we could have saved, but even we cannot be 100% certain”.

The Hospital ascertained that it was not due to negligence with COVID, but ideally lack of ambulance that delayed the process of referral. There could be multiple reasons, we can’t find where the fault is, but the CT Scan report urged us to refer the patient, maintained Namchi District Hospital.

External Supervision by a Forensic Expert

Dr, OT Lepcha, Forensic Expert from STNM Hospital, who was welcomed as an external investigator to the case by CRH Manipal management. “The patient was referred with blood in the brain from Namchi, based on that they came. The postmortem to be conducted showed massive bleeding, it was a blood clot on a 42-year-old.

The concern is the patient being kept outside Manipal for hours, the patient party came with hope. Had he died at Emergency, it would have been a different story, but the doors not opening is the allegation. There cannot be an excuse of COVID being spread and the hospital going through sanitization and change in shifts. There has to be minimal investigation that should have happened. The person not being treated for 1.5 hours, those doctors and nurses should have acted”.

The postmortem by CRH Manipal was conducted in the presence of Dr OT Lepcha but conducted by Manipa’s Forensic Expert. “It showed massive bleeding and matching with the history of the patient. Namchi ambulance could be on COVID duty, they invited their own vehicle. It appears they left around 2 pm. It appears that he did go through an increase in blood pressure, he might have suffered a stroke, lost consciousness and then fell from the bed. The haemorrhage was so hard that the left side of the brain has pressed against the right side, so he is bound to lose consciousness. The finding is that only, the report has nothing to hide”.

CRH speaks in anonymity

A senior doctor from Manipal requesting anonymity maintained, “It was a case of head injury with loss of consciousness but Namchi Hospital did send without any basic life support management in a Tata Sumo from Namchi. Incident happened in the morning at Namchi but patient brought to CRH at 7 pm. Other hospitals get sealed on exposure for days, the hospital had a positive exposure at 6:30 pm, so was sealed as per guidelines.

By the time the unexposed staff team arrived by 8 pm, when the assessment was done, the patient was no more. In cases of head injury, the golden hour is the first few hours after the injury, this patient wasn’t even managed prior”.

Another doctor from CRH Manipal continued, “The health professionals are already overworked and overstressed due to risk of COVID-19. When allegations made against them without allowing them to explain the situation thoroughly. They work tirelessly and they are never negligent in carrying out their duties.

Attacking them through media and social media will only break their reserve and crush their spirit. Patients under the care of health care professionals, upon learning of the hospital’s alleged negligence will lose faith in the management for treatment of their illness. In return, they will look at the doctor or the assisting nurses with suspicion and malice. This will be detrimental to their psychology and in turn may harm their recovery. It was an unmindful and hurried ways of news reporting will cause sensationalism but will not bring about any productive change.

We the frontliners need your support in this crucial time to understand our side of the story, and not be heckled in a press conference for the sake of asking questions”.

By Pankaj Dhungel, Journalist at East Mojo & Sikkim Express. The author can be reached at pankajdhungelsikkim@gmail.com

Views/Opinions expressed in the article or write up is purely of the author/writer and not of The Sikkim Chronicle, including statistical data, which was provided by the writer. For any queries or contradictions, the author can be contacted in his/her email id.