PESHAWAR: A preliminary investigation report has been submitted in the oxygen shortage at Khyber Teaching Hospital Peshawar that resulted in the deaths of six patients.
The report stated that seven officers, including the Medical Training Institute (MTI) hospital director Dr Tahir Nadeem Khan, have been suspended.
The incident came to light on Sunday and notice was taken by Health Minister Taimur Jhagra and Chief Minister Mahmood Khan.
Jhagra has announced action against those responsible. Five of the patients who died were in the COVID isolation ward and one was in the ICU, according to the report..
Among other things, the inquiry found that while the MTI has an oxygen storage tank of 10,000 cubic meter capacity, it is never filled to capacity. There is no backup system for oxygen supply as recommended by the health technical memorandum. “Ideally there should either be a primary backup (another tank) or secondary backup (manifold),” it noted.
M/S Pakistan Oxygen limited has the contract to supply oxygen to the hospital but the contract 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.
The report also found that the staff at the oxygen plant lack proper technical skills and training. The on duty manager of services received a call from main operation theatre about low oxygen pressure and called the oxygen plant operator, but he was not picking up. He then physically visited the plant and found that the two on duty staff members were not present.
The pressure at the plant at the time was zero according to the pressure gauge reading. The report said the oxygen plant assistant failed to perform his duty as he is responsible for the oxygen plant and has a liaison with the supplier.
At the time of the incident, there were 90 patients at the hospital, 20 on BiPAP, two on ventilators and the remaining on mask oxygen. The hospital ordered 13 patients to 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 supply.
There was no organized emergency rescue squad at the hospital as required for disaster management under such conditions, the inquiry found.
“Six patients in the isolation ward expired. Three patients were missing, one is still untraceable and the other two were traced and are alive.”
It found that the Hospital Biomedical Engineer and his technical team have failed to train the oxygen plant staff to monitor and maintain the service history and look after the biomechanics of this important life-saving equipment.
Here are the conclusions reached by the inquiry team:
There was a system failure at the hospital
Chronic deficient oxygen filling of the tank, which went unnoticed, unsupervised and unchecked
No backup supply of oxygen storage/supply system
Facilities management failed to report the absent staff of the oxygen plant
Supply chain department failed to provide required number of oxygen flow meters for the oxygen cylinders
The hospital has no emergency rescue squad
The oxygen plant staff needs further training and skills enhancement
The biomedical engineer failed to perform his duties
The report was prepared by a three-member team of the Board of Governors.
