Twelve days after a fire killed 10 newborns in Bhandara district general hospital, the Maharashtra government on Thursday suspended district civil surgeon Dr Pramod Khandate along with the on duty medical officer of the hospital, Dr Archana Meshram, and sister in charge Jyoti Bharaskar.
While additional civil surgeon Dr Sunita Bade was transferred, the contract of paediatrician Dr Stuti Ambade and two staff nurses – Smita Sanjay Ambil Duke and Shubhangi Sathavane – of the hospital were terminated.
“The district civil surgeon and medical officer will remain suspended until the departmental inquiry is over,” Public Health Minister Rajesh Tope told The Indian Express.
The decision comes a day after Nagpur Divisional Commissioner Sanjeev Kumar submitted an inquiry report into the fire incident to Health Secretary Dr Pradeep Vyas.
Kumar was heading a six-member committee that probed lapses leading to the fire in Bhandara hospital. The fire had occurred between 1 am to 1.30 am on January 9.
The committee has held civil surgeon Khandate and additional civil surgeon Bade responsible for negligence and the hospital suffering from lack of maintenance.
The report held Khandate responsible because he was the overall supervisor of the hospital and responsible for repair and maintenance work. The two were also responsible for ensuring adequate staff for the hospital.
The report stated that on duty nurses Duke and Sathavane were not at their nursing station at time of the fire. Sister in charge of the Sick Newborn Care Unit (SNCU), Bharaskar, was held responsible for not ensuring that the nurses were present at the nursing station.
Medical officer Meshram and paediatrician Ambade have been held responsible for not being present at the SNCU at the time of the incident though they were on duty there.
At the time of the incident, both the nurses had stepped out “to fill some report” after feeding all the babies. Meshram, posted in the ward, was treating patients in another ward. Ambade was also not present there, the report said.
The two nurses had rushed back only after they heard the first explosion in a radiant warmer. By then, a seven-day-old baby had charred to death in the exploded warmer, the report added.
The report further said that fire began in a radiant warmer control panel following a spark. It is suspected that voltage fluctuation led to the spark.
The conductor in the control panel was worn out, the report added.
The fire spread through mattresses and plastic in two other warmers. It melted the central oxygen pipe that runs through the ceiling and the wiring of SNCU. This led to a lot of smoke. Seven of the 10 babies in the “outborn section” of the SNCU died due to smoke inhalation and suffocation. Three babies died due to burn injuries, the forensic report has stated.
The inquiry committee has recommended that trained electrical and biomedical engineers be appointed to handle equipment and electric appliances in the hospital.
Tope said this recommendation will be implemented. “We have also told private agency Faber Sindoori to be vigilant in inspection of biomedical equipment,” he added.
Faber Sindoori has been contracted to maintain biomedical equipment in government hospitals of Maharashtra since 2017.
Moreover, the report has raised concerns over the need to have proper coordination between the public works department and the health department to maintain all hospital buildings. “I have written to all district guardian ministers to provide funds from the District Planning and Development Council for audit and repairs in hospitals. In the coming days, we will see several changes,” Tope said.
A fire audit in all government hospitals is already underway. In a fortnight, districts will submit a proposal to instal more fire safety systems.
Tope said CCTV cameras will be installed in hospitals and National Building Code guidelines followed for future hospital constructions and upkeep.
The Bhandara hospital has been allotted Rs 1 crore to undertake repair of the damaged SNCU. The hospital started functioning in 1981 without a no objection certificate (NOC) from the fire department.
In 2015, when the hospital constructed an extension to open SNCU, a medical store and a nutrition rehabilitation centre, for a second time, NOC from the fire department was not obtained.
While inquiry committee members have raised concern over who is responsible for granting of such permissions, Tope remained silent over whether PWD will be held responsible.