• Report finds oxygen tank never filled to required level
• CM orders termination after detailed probe
• Jhagra announces Rs1m compensation for each family

PESHAWAR: A fact-finding committee constituted to probe the death of six patients due to lack of oxygen at Peshawar’s Khyber Teaching Hospital has recommended suspension of the hospital director, two managers and three other employees, besides blaming the vendor for failing to supply oxygen on time.

Terming the suspension of KTH staffers insufficient, Chief Minister Mahmood Khan instructed the hospital’s board of governors to conduct a detailed inquiry, fix responsibility and take strict action such as termination from service. The committee was given five days for detailed probe and chalk out further course of action and it was decided that the chief minister would hold a meeting by Friday to review progress on the matter.

Dr Tahir Nadeem Khan had served as director general for health and health services in Khyber Pakhtunkhwa, besides having worked as a national consultant with the WHO and a Unicef consultant in 2019 before being appointed to the position of hospital director in July 2020 for a period of five years. Shortly after his suspension, former dean of Khyber Medical College Prof Rohul Muqeem, a laparoscopic surgeon who had remained hospital’s medical director, was made acting director.

Besides Dr Tahir, the inquiry committee meeting held under the Board of Governors chairman Prof Nadeem Khawar along with two members Naveed Alam and Sabur Sethi suspended hospital’s facility manager Tahir Shehzad, supply chain manger Ali Waqas, biomedical engineer Bilal Babak and three oxygen plant workers namely Waheed Khan, Shehzad Akbar and Niamat Khan.

According to sources, the issue of shortage of oxygen at the hospital dates back to 2017. An insider said a former member of the BoG had in 2018 drawn the attention of its members towards the lack of disaster management system at one of the major teaching hospitals in Peshawar. However, that member resigned after finding no traction with the BoG that continued to drag its feet on important issues such as disaster management, the source added.

Others privy to the hospital issues were of the opinion that the committee made the director a scapegoat at the behest of ‘vested interests’ who wanted him out for stopping their interventions in procurement, as responsibilities of the board of governors for putting in place a disaster management system at the hospital had not been investigated.

While chairing a special meeting regarding the probe into the six deaths at the teaching hospital, CM Khan on Monday reviewed the preliminary inquiry report. He appreciated the BoG for conducting the inquiry within 24 hours instead of 48 hours, a statement said.

However, he termed the suspension of KTH staffers insufficient and instructed the BoG to conduct further inquiry into the matter, fix exact responsibility and take strict action. He made it clear all those found responsible would not be spared at any cost, warning the BoG if it didn’t take strict action against the real culprits, the government would itself conduct an independent inquiry and take action.

The four-page investigation report found that the Khyber Teaching Hospital (KTH) had only one oxygen storage tank of 10,000-cubic-metre capacity with no backup supply system against recommendation of the Health Technical Memorandum, according to which there should be either a primary or a secondary backup.

It said that the KTH awarded a contract to “Ms Pakistan Oxygen Limited on February 11, 2015 that expired on June 30, 2017. However, no office order regarding renewal/extension of contract since then was available. The manager supply chain verbally confirmed extension of the contract over the phone on June 30, 2020, it said.

According to the contract agreement, the first party (Ms Pakistan Oxygen Limited) was responsible for the supply throughout the mentioned period without any break and in case of any fault/service/repair in the plant required, the first party will inform the second party (KTH) in advance.

The oxygen tank supplied by Ms Pakistan Oxygen Ltd is equipped with telemetry and pressure gauge system. The company customer engineering services can check and verify the level and pressure of the oxygen in the tank at any point in time through telemetry. The operator on duty can check and verify the level and pressure of the oxygen in the tank at any point in time with the help of pressure measuring gauge.

Although the hospital oxygen tank has storage capacity of 10,000 cubic metres, as per available record, the supplier has never filled it to the required level. On December 4, 2020, the KTH received only 3,040 cubic metre of oxygen, which was far below the tank’s storage capacity despite the fact that the tanker had 7,140 cubic meter oxygen in it.

On the same night, Manager Services Amir Khan received a call from operation theatre regarding low oxygen pressure who subsequently tried to contact the plant operator, but he didn’t pick the call. He then visited the plant and found out that the two persons supposed be on duty were absent. The pressure in the oxygen plant at that time was recorded zero, according to the inquiry report that said an assistant, Mr Niamat, who is responsible for the oxygen plant and has a liaison with the supplier, failed to perform his duty.

According to a press release, the standard of monitoring and supply system of the Pakistan Oxygen Limited, supplier of the oxygen, would be further investigated, qualified and trained staff be hired and primary and secondary backup and proper command and control system for oxygen plant would be established. An emergency rescue squad would be organised for better preparedness in future, it said.

Compensation

KP Health Minister Taimur Khan Jhagra announced Rs1m compensation for the family of each person died for want of oxygen at the hospital.

He said the inquiry committee should bring the hospital flaws forward instead of hiding them. “Lack of oxygen should have been identified in time,” he remarked.

The hospital’s board of governors has been given five days for further action after detailed inquiry report to be submitted on Friday.

Published in Dawn, December 8th, 2020