PESHAWAR: On the recommendation of an inquiry committee, the board of directors of the Khyber Teaching Hospital on Tuesday directed former hospital directors Dr Mohammad Zafar Afridi and Dr Nek Dad Afridi to explain position on negligence of duty over the death of seven patients due to oxygen shortage earlier this month.

It also issued show cause notices to four staff members of the hospital, including supply chain manager Ali Waqas, biomedical engineer Bilal Khan, oxygen plant assistant Niamat Ali and oxygen gas attendant Shahzad Akbar, over the deaths giving them seven days for response.

All board members, including the chairman, later tendered resignation from their offices.

In its report released in the day about deaths, the inquiry committee formed by the health department with Prof Nadeem Khawar as chairman and Nadeem Aslam and Mohammad Saboor Seithi as members recommended that the board members resign ‘keeping in view the high moral ground, dignity and integrity’.

All BoG members including chairman tender resignation

The report declared that the oxygen supply failure, which took place during the night between Dec 5 and Dec 6, caused the loss of seven lives.

It said initially, six deaths were reported, including five in the COVID Ward and one in the intensive care unit.

A two-year-old child died later at night with interrupted oxygen supply likely to be a contributing factor to the death.

The report revealed that the MTI KTH had awarded the contract of oxygen supply to the Pakistan Oxygen Limited on Feb 11, 2015, which expired on June 30, 2017.

It added that the contract was neither extended nor was it re-advertised until Jan 6, 2020.

According to the report, Dr Mohammad Zafar Afridi, the then hospital director, extended the company’s contract until June 30, 2020, but it wasn’t extended.

In light of the committee report, the board of governors issued a charge sheet to Dr Tahir Nadeem Khan of BPS-20 over deaths and repatriated him to the health department after cancelling his contract as the KTH hospital director.

It also issued separate charge sheets to the then hospital directors, including Dr Zafar Afridi and Dr Nek Dad Afridi, over ‘failure to perform their administrative duties in their tenure to address this sensitive issue. They’re told to submit reply within seven days.

The subcommittee submitted its report to the BoG on Dec 21, 2020.

In light of that report, the board of governors issued show cause notices to hospital employees Ali Waqas, Bilal Khan, Niamat Ali and Shahzad Akbar for explanation within seven days over deaths and said if they wanted to be heard in person by the committee, they could contact it.

It also said in the report that KTH manager (human resource) Yousaf Jamal and manager (facilities) Tahir Shahzad would be working in the KTH until Dec 31, 2020, and their contracts wouldn’t be extended in line with the recommendation of the inquiry committee.

The board said AC plant helper Abdul Wahid was not involved in the incident as he was present on duty and therefore, he was exonerated of the negligence charge.

It issued a warning to medical director Prof Amer Azhar for not strengthening the early warning system in clinical wards and intensive care unit.

The inquiry report said there was no record of either of the hospital director or the officials responsible for managing the oxygen supply, proactively demanding the oxygen supply company to fill the tank to full capacity at least once to maintain a reserve or of brining the issue to the notice of BoG.

According to it, even on Dec 4, a day before the deaths due to oxygen shortage, the supplier had only supplied 3,040 liters of oxygen resulting in suboptimal utilisation of the tank’s capacity, which could have provided greater backup supply if kept fully filled.

It said the maintenance of oxygen supply was looked after by Niamat Ali, a responsibility handed him over informally by the successive hospital directors, who also failed to put in place a proper check and balance system or a mechanism of meaningful supervision.

“The inquiry committee found that he (oxygen plant operator) lacked the requisite qualifications and skills for such an assignment,” the report said.

It added that during investigation, it came to light that most of the officials responsible for some stage of the supply chain management of oxygen to the wards, continuously failed to perform their duties.

The report said those officials chose to let the system function in status quo and never brought the matter to notice of BoG.

“In nutshell, the committee found that Dr Tahir Nadeem and his predecessor failed to perform their primary responsibility of managing the affairs of oxygen supply in an efficient and effective manner.

“Dr Tahir Nadeem and the previous hospital directors, Dr Nek Dad and Dr Mohammad Zafar Afridi, failed to develop proper chain of command and control for the central oxygen delivery system.”

The report said there were no standard operating procedures in place for proper operations, maintenance, monitoring and supervision of VIE oxygen tank.

“Proper networking/routing of copper piping was not done in accordance with the need and requirement of individual wards and sections. Similarly, no primary or secondary backup systems were installed for ensuring uninterrupted oxygen supply to the patients.”

Published in Dawn, December 23rd, 2020