No action ordered against the erring staff
A medical enquiry into the death of a woman days after delivering a baby boy at Lal Ded hospital in June this year has found the blood transfusion protocols were not followed at the hospital as a nursing orderly began the transfusion without informing doctors and taking written consent of the patient’s family.
The patient suffered blood transfusion reaction and, according to her family, never recovered after that.
However, Government Medical College (GMC), Srinagar, has not ordered any action against the erring staff.
The enquiry report said the patient suffered transfusion reaction and Disseminated Intravascular Coagulation—formation of blood clots in small blood vessels throughout the body.
It concluded the doctors had not ordered the transfusion and “a proper receipt with the signature of a doctor on duty was not taken on blood form”.
Although the report does not specifically mention the transfusion led to the patient’s death, the victim family said the patient never recovered after the incident.
The enquiry also observed “resuscitation measures in labour room could have been more prompt and more effective”.
The enquiry report also read, “As per written by a technician on duty transfusions issued on pressure by attendants.”
The 35-year-old woman, Shaheena Bano, was admitted at the hospital on May 31 and the unordered transfusion was done on June 2. Bano delivered a baby boy later in the day though caesarean section (surgery).
According to the hospital authorities, Bano suffered blood loss and multi-organ failure and was referred to Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, for hemodialysis—a process that uses a man-made membrane (dialyzer) to remove wastes, such as urea, from the blood when kidneys stop functioning.
She died at the Institute on June 6.
The enquiry report says the patient was shifted to the Institute “as per the decision taken by on-duty staff and intense pressure by the attendants and in patient’s best interest”.
Medical Superintendent of Lal Ded hospital, Dr Nazir Ahmad Malik, told Rising Kashmir the hospital has not received any direction from the GMC regarding the case. Malik was a part of the enquiry team.
Malik said the crime branch of the Jammu and Kashmir Police is also investigating the case. “I don’t think transfusion by a nursing orderly or a doctor could have caused the death of the patient,” he said.
Contrary to what the enquiry report suggests, GMC Principal, Dr Samia Rashid, said no doctor is guilty of medical negligence.
“The patient was given platelets (blood) and was found to be having transfusion reaction and causing hypertension. She was immediately rushed to the theatre where from she was rescued and she could not stop bleeding after that,” Dr Samia said.
She said the doctors had to remove her uterus but she ‘began bleeding from all sources’.
“Because of that the blood pressure dropped, the kidney function got deteriorated and she developed multi-organ failure for which she was shifted to SKIMS, Soura, for hemodialysis,” she said.
Dr Samia said the patient’s relative started the transfusion. “Doctor was not informed about the transfusion,” she said. “There is no question of negligence. It can happen to one in ten thousand [patients].”
The deceased patient’s family has since been demanding action against those responsible for her death. “The negligent hospital staff should be put to task and punished so they would not repeat such act again,” her husband, Tariq, said.
He said his three-months-old baby, Imaad, cries for her mother’s milk. “I want justice. The hospital staff responsible for my wife’s death should be punished. I am suffering mental trauma,” he said.
Smelling gross negligence, Tariq said he filed an application under Right to Information Act, on June 10, asking the hospital the number of hematologists who work there and their qualification.
He found the hospital does not have a designated post for hematologists.
Tariq said the family was not even provided a critical care ambulance to shift the critically ailing patient to SKIMS. “At that time, the hospital authorities refused to provide the critical care ambulance. They asked us to manage the ambulance by our own, which was unfortunate,” he said.
He said the family arranged a critical care ambulance from a Non-Government Organisation, Save The Poor.
“It is shame for the hospital that there was no such ambulance that day,” Tariq said.
Pertinently, after the enquiry report was prepared, Minister of State for Health, Asiea Naqash, called for action against the negligent staff, but no action has been taken so far.