Inquiry report holds former, current directors responsible for COVID-19 deaths in KTH

Former and current directors of the Khyber Teaching Hospital (KTH) has been held responsible for failure of proper oxygen supply in the hospital, says an inquiry report.

The report was made public by Khyber Pakhtunkhwa Finance and Health Minister Taimur Khan Jhagra on Tuesday via tweet stating: "As promised, the KTH inquiry [was] completed by the MTI board, and as promised, GoKP is making it public immediately."

In the unfortunate incident six coronavirus patients — six in the coronavirus ward and one in the intensive care unit (ICU) — passed away in the hospital due to lack of oxygen supply.

"This standard of transparency is important if we are to continue the journey of continuous improvement of our health system, a core commitment of our govt," he added.

As per the report the incident took place during midnight between 05.12.2020 and 06.12.2020 when the Oxygen supply front VIE tank was completely exhausted, the initial alarm came from the COVID isolation ward and the Operation Theatre (OT) at 12 midnight.

At that time 90 patients were under treatment in the isolation ward. Due to the inefficient mechanism of monitoring oxygen levels alarms in the ward were raised by the available staff only when oxygen levels depleted to near zero level.

"Had the alarm system been properly installed (e.g. extension of interface to wards) or adequately monitored (through an efficient system) then the initial alarms could have been raised when the level of oxygen dropped to 300 litres in the oxygen tank (trigger level of central alarm system in oxygen tank room). This would have saved many lives," the report noted.

Following the incident, the Board of Governors have issued charge sheets to the managers and subordinate staff who were related to the incident and formed a three-member inquiry committee to fix responsibility and recommend necessary action.

"The BOG itself conducted the enquiry for fixation of responsibility against officials above managerial level [hospital directors in this case] under the relevant rules," it added.

The BOGs also carried out its own inquiry into the officials above managerial level, the report noted.

In addition, the BOG chairperson and all five Board members have submitted their resignations on "high moral grounds, dignity & integrity", while the report has been sent to Khyber Pakhtunkhwa Chief Minister Mahmood Khan.

Furthermore, the report added that the staff responsible for the oxygen supply were negligent of their duties as were the current and former directors in ensuring system's improvement.

In its recommendations, the committee directed for action against those involved, including the biomedical engineer, human resources manager, and oxygen plant assistants and staff.

The team — under Director-General Health Services (DGHS) Dr Tahir Nadeem and comprising Human Resources Manager Yousaf Jamal, Facilities Manager Tahir Shahzad, Supply Chain Manager Ali Waqas, Biomedical Engineer Bilal Khan, and Oxygen Plant Assistant Niamat Ali, as well as two support staff, Oxygen Gas Attendant Shahzad Akbar and AC Plant Helper Abdul Wahid — "failed to establish a well-functioning oxygen supply management regime, or to improve the facilities available, in the context of the crisis at hand".

The report also find that a vacuum insulated evaporator (VIE) oxygen supply contract — awarded to the Pakistan Oxygen Limited (POL) — expired on June 30, 2017, but was extended until June 30, 2020, by then-hospital director Dr Muhammad Zafar Afridi.

Former directors, including Dr Nek Dad, Dr lrshad Ahmad, Dr Inayat Ur Rahman, and Dr Afridi, "failed to advertise/extend the supply contract of VIE oxygen during their respective tenures", as did Dr Tahir Nadeem, it said.

Regardless, the POL continued supplying oxygen regularly after June 2020 despite the contract having expired earlier.

A back-up oxygen manifold system was decommissioned in 2017 for the construction of another project but was none of the hospital directors, including Dr Dad, Dr Afridi, and Dr Nadeem, "bothered to re-commission the backup system", with the "negligence becom(ing) even more damaging in the presence of COVID-19 pandemic", the report said.

More than one of Dr Nadeem's claims were found to be false and his neglected duties as well, the report added.

Findings

• Hospital never demanded for more oxygen than that supplied by the POL despite having additional capacity in the VIE tank.

• Required accessories, oxygen flow metre, and pressure gauge were
  found to be grossly deficient on the night of the incident despite
  presence of 260 portable oxygen cylinders.

• The staff deputed at oxygen plant of the KTH did not possess
  pressure measuring gauge.

• The oxygen plant assistant/operator was looking after the
  maintenance of oxygen supply as a "responsibility handed over to
  him informally by the previous hospital directors" but the
  individual "lacked the requisite qualifications and skills for
  such an assignment".

• Most of the officials responsible for some stage of the supply
  chain management of oxygen to the wards continuously failed to perform their duties and never brought the matter to the notice of BOG.

• Dr Nadeem and his predecessors failed in their primary
  responsibility of managing the affairs of oxygen supply of KTH in an efficient and effective manner.

• Dr Nadeem failed to timely intimate the incident report to
  the relevant quarters, that is, the Board of Governors,
  Secretary Health, and the Health Minister; he also arrived at the scene after 2am and told the Board he
  did not inform anyone since it was an administrative
  matter.

• The committee noted that "ideally the oxygen plant should
  have been operated through a Biomedical
  Engineer/Technician".

The Board underlined that Dr Nadeem would be immediately terminated and repatriated to the parent department, whereas Dr Zafar Afridi and Dr Dad will be served with charge sheets. The medical director, on the other hand, would be warned to strengthen the early warning system in clinical wards / intensive care.