Experts trash enquiry panel report on COVID oxygen deaths in top Goa govt hospital; call for pan-India probe

Medical experts have slammed a report given by a three-member committee appointed by the BJP-led Goa government to probe the alleged oxygen supply issues at Goa Medical College & Hospital (GMCH) in May, during the height of the second wave of COVID-19, which said that the hospital administration failed to flag the issue in time even as it concluded that the deaths could not be attributed to shortage of oxygen, as just an orchestrated attempt to give a clean chit to the government. The 35-page report also said that it didn’t “find anything unusual” in the number of deaths between May 11 and 13 as compared to other days.

As per reports carried by the media, including National Herald, between May 9 and May 14, GMCH — Goa’s top medical institution that treated most of the critical Covid-19 patients — saw 188 Covid deaths of the total 323 reported across Goa. After a liquid medical oxygen (LMO) tank became functional there from May 15 to May 19, it accounted for 104 of the total toll of 230. However, this corresponded with a drop in the number of active cases at the time too.

As per media reports, at least 80 COVID patients died due to the shortage of oxygen in the premier, State-run hospital.

The committee, which consisted of IIT Goa Director Dr B K Mishra, former dean of GMC Dr V N Jindal and revenue secretary Sanjay Kumar, stated that on three days – May 11, 12, 13 – “it was alleged that GMC had witnessed a large number of deaths between 02:00 hrs to 06:00 hrs, due to lack of oxygen….The committee could not find anything unusual in the number of deaths for those three days as was reported in the media, as compared to the other days,” the report said.

“Incidents of pressure drops were quite likely to occur during changeover of empty trolleys, especially due to the late arrival of the next trolley. Any drop in pressure activates an alarm in the wards. The committee concludes that such incidents did occur and caused panic among patients and healthcare workers. However, the committee could not conclude that such intermittent incidents of drop in pressure were long enough to cause loss of life… At high demand times, the trolley system based supply might have failed to supply adequate oxygen, especially at the tail end of the supply chain, even if it did not cause any death,” the report said, as per sections of the media.

Speaking to National Herald, Dr. Ishwar Gilada, an infectious diseases expert who raised the alarm against HIV-AIDS in India back in 1985 and is serving as secretary-general of Organised Medicine Academic Guild (OMAG) – a federation of 15 professional associations of post-graduate doctors in India, covering 250,000 consultants – said that the committee’s constitution itself was questionable.

“It consisted of members like the state revenue secretary and a former GMC dean who are ‘interested persons’ in terms of the fact that they are at the government’s mercy so far as their salary and pension etc are concerned. They could hardly have been expected to do a fair job,” he said.

He also pointed out that out that a probe into such a grave situation should have been carried out in a couple of days and a report released immediately. “How could it have taken months, as is the case?” Dr Gilada said. The report was submitted to the Goa government only on July 23, which came to light only on Monday.

“The fact that any patient dies because of shortage of oxygen in a reputed hospital is itself a pathetic situation,” he said.

Dr Gilada said that the committee was clearly trying to make the hospital administration as a scapegoat to spare embarrassment to the government.

“This is ironical, considering that the state government itself runs the hospital and the buck stops with those at the top who were in-charge of supervising its functioning as well as policy decisions,” he said.

Incidentally, Goa Health minister Vishwajit Rane had acknowledged on May 11 that 26 Covid-19 patients had died in the Goa Medical College in the early hours of the day when supply of oxygen was interrupted. That was also the day Goa recorded its single-day-highest mortality count of 75.

However, ten days after Union Minister of State for Health & Family Welfare Bharati Pravir Pawar stated in the Rajya Sabha on July 20 that “no deaths due to lack of oxygen have been specifically reported by states/UTs” during the second wave of COVID, which led to a nationwide outrage, Rane did a complete U-turn.

“..no deaths have been directly attributed to the lack of oxygen. But definitely consumption per patient increased due to the strain of covid-19,” Rane said in a written reply to a question asked by independent MLA Rohan Khaunte in the Goa Assembly.

Speaking to National Herald, paediatrician Dr Kafeel Khan, known for his efforts to try save children at Gorakhpur's BRD Medical College where around 60 children had died in August 2017 due to an alleged shortage of oxygen – even as UP government went on to suspend him by pinning the blame on him, a matter currently under adjudication in Allahabad High Court – pointed out that the probe committee was set up in the first place only because of Rane’s public acknowledgement of the issue.

It may be recalled that the Goa Association of Resident Doctors had first flagged the issue of oxygen shortage in GMCH on May 3. After the high court took up the matter, Rane called for a probe into the deaths.

Dr Khan too questioned the credentials of the probe committee members.

“Such a probe committee should have had independent and unbiased experts from the medical field, that too from outside Goa. How is Goa IIT Director or state revenue secretary eligible to look into such a technical matter? And the only other person from the medical field obviously couldn’t have digressed from the narrative the government wanted to put out, especially with the Assembly elections around the corner,” he said.

Dr Khan pointed out that even though the report was aimed at giving a clean chit to Goa government, it had acknowledged that oxygen pressure had indeed dropped during “changeover of empty trolleys”.

“Firstly, such a large and well-known medical facility should have had a Liquid Medical Oxygen facility installed much earlier rather than after so many patients had died. It is an inexplicable thing in an era when the world over, this is the norm,” he said.

“Much more importantly, it is a basic medical fact that oxygen is an essential medical emergency drug – a hospital can have water or electricity supply failures but oxygen supply cannot be interrupted – and that deprivation of oxygen being administered to a critical patient even for a minute can lead to hypoxia. Hypoxia causes derailment of body metabolism that leads to multi-organ failure and eventually death. It can be irreversible, which means even the best medical facilities or doctors can’t do anything about it. This is why several children at BRD Medical College had died days after the oxygen supply was interrupted,” he said.

Dr Khan said even though the government may be in denial about it, it was a well-known fact that deprivation of oxygen had led to a huge number of deaths not only in Goa but all over the country between April 19 and May 5. “A proper probe to fix accountability needs to be done all over the country,” he said.

Dr Gilada too emphasised on this. “A pan-India enquiry is imperative, to prevent such a human tragedy the next time around if nothing else,” he said.

It’s pertinent to mention here that Dr Gilada had, in a conversation with National Herald highlighted, shortly after the Centre’s statement in Parliament on the issue, that it was ICMR guidelines which had prevented states from reporting such deaths.

The Goa probe committee report was, incidentally, also slammed by senior Congress leader P Chidambaram on Monday, who termed it as “a desperate attempt to give a clean chit” to the state’s Bharatiya Janata Party (BJP) government.

“The Hospital is blamed but the government is not to be blamed! Strange logic in respect of a government-OWNED hospital!” Chidambaram tweeted on Monday. “Why does the Goa government have a Department of Health and a Minister of Health, if they are not responsible?”

Chidambaram, who is the Congress’ election observer for poll-bound Goa, called for chief minister Pramod Sawant and health minister Vishwajit Rane’s resignations on the issue.