A report of the independent investigation by Jan Swasthya Abhiyan, Narmada Bachao Andolan and Swasthya Adhikar Manch into the patients losing their eye sights as a result of an eye cataract surgery camp jointly organized by Barwani District Hospital and Lion’s Club between 16 and 24 November, 2015, under the District Blindness Control Programme, was released in Bhopal on 15 December, 2015. Thereafter, the Madhya Pradesh government announced compensation of Rs 2 lakh each to each of patients impacted by the surgery, along with a monthly pension of Rs. 5000 for 65 patients out of the total 86 patients. A updated investigation has found serious gaps found in the whole process. Excerpts from the new report:
Violations of Guidelines of the National Programme for Control of Blindness
The government has put in place norms of service delivery under the National Programme for Control of Blindness. It is essential that all eye surgeries follow these guidelines during pre-operative, operative, and post-operative procedures. It is clear that gross violations had happened on multiple aspects in the Barwani Eye Camp.
- As per guidelines, only glass bottles of Ringer Lactate/normal saline should be used. However, it is known that plastic bottles of solutions were used.
- The guidelines state the fumigation standards to be followed for Operation Theatres (OT) before and during the operations. It mandates that the hospital maintains a proper fumigation record of the OT. The fumigation records of the OT-s used during the eye camp at Barwani District Hospitals during the period of the camp should be made available to the public.
- The guidelines mandate that pre-operative vision of the patient and the vision at the time of discharge should be taken and recorded on the discharge ticket. However, no discharge ticket is available at this point in time to validate whether this was followed or not. This would have provided crucial information on whether patients were discharged only after expected vision was achieved after surgery.
- The guidelines state that non-cutting instruments should be autoclaved with standard procedures and all cutting instruments should be kept in cidex or equivalent potent solution for at least 8 hours. Instruments need to be disinfected and washed in between surgeries. The hospital should be made accountable if there have been any violations in this regard.
AIIMS investigation report has further confirmed that infections spread due to bacteria in OT and surgical instruments.
Status of Government Investigation
There have been multiple rounds of investigations by various State teams so far. The first rounds of investigations on 4th December, 2015 had raised concerns on the standards of operation theatre. The second round of investigations by District Blindness Control Society (DBCS) teams on 6th December, 2015 had expressed concerns over drugs used during surgery. The AIIMS investigation on 7th December, 2015 had raised violations on the operation theatre again. Finally the investigation team comprising of Deputy Director, Health, Finance department and Dean MGM Hospital on 22nd December, 2015 carried out a hurried investigation details of which were kept under cover.
No investigation report is available in the public domain so far.
The questions we would like to voice are:
- Such investigations should be made time-bound. The government should disclose the timeline by when the investigation will be completed and a date when the investigation report would be published and made available to the public
- The samples of the drugs used during the surgeries were sent for lab test more than a month ago. The lab test reports should be published without any further delay.
- There is a conflict of interest whereby Dean, Mahatama Gandhi Memorial (MGM) Medical college, Indore Dr. Rathod was part of the investigation team and he was also part of the treatment team of the patients in MY hospital and SAIMS hospital, Indore. A justification needs to be provided by the State on this matter.
- Strict action should be taken against the offending doctors/medical officers/collector/and others with involvement in the camp. Suspensions of Collector, CMHO and nodal officers of National Blindness Control Programme whosoever found guilty, may be ordered.
Procurement of Drugs
It is yet not clear whether drugs, solutions, injections used in pre-operative, operative and post-operative periods were procured at the State level or at the District level.
The following should be made clear to the people:
- The details of the procurement process followed
- The details of all drugs/solutions/injections along with names of pharmaceuticals companies/distributors/contractors that were used in pre-operative, operative and post-operative periods
- All quality test reports of drugs/solutions/injections used
- Whether any sub-standard drugs were procured/used and whether any banned companies/contractors were involved in the procurement process
65 patients were sanctioned pension. One patient passed away, one is a child. Where are the rest 19 patients? What is their condition?
There were a total of 86 patients who were operated in the camp. The media has published a list of 65 patients who were sanctioned Rs. 5000 monthly pension as per press note issued by District Public Relations Officer. We assume they will also be given the compensation amount. The question is where are the rest 19 patients? What is the condition of their eyes?
Our team working on the ground located most of these patients who were left out of the pension and compensation process. These patients were not referred to SAIMS in Indore.
As per the investigation and statements collected from these patients, at least 12 patients were found who have not got back expected vision in their eyes. Most of them cannot see too far, have water falling from their eyes and have hazy vision. Clearly they have not got their eye sight back and are suffering from problems even after almost 2 months since the surgery.
It is unknown based on what protocol they were not referred to Indore for treatment. Most of them have visited Barwani District Hospital and Sendhwa Hospital 6-10 times since their surgery and they are still running back and forth to these hospitals.
- Immediate arrangements for treatment for each one of them at higher level
- Immediate sanction of compensation and pension as they have fully or partially lost their eye sight
Sildar son of Harsingh, Balkhar, Sendhwa: Sildar was admitted to Barwani District Hospital on the evening of 16th November, 2015 and his right eye underwent opeartion on 17th November, 2015. He was discharged on 18th November, 2015. Soon after, he started having pain and watering in his eye. He was re-admitted to Barwani Hospital and discharged after 3 days. However, the problems continued. He has not been referred to Indore for treatment. Since then, he has visited Barwani District Hospital, Sendhwa Hospital and Chachriya hospital 8-9 times. Every time he goes to the hospital, his neighbor takes him on his motor cycle and Sildar pays for the petrol cost. He has not got back normal vision in his right eye till today. Sildar has cataract in his other eye too (left eye). Thus he cannot even move around without someone helping him. He has not received any compensation and his name does not appear in the list of patients who have got pension.
Rahisa, wife of Babushah, Anjhad, Thhikri: Rahisa, aged 70 years, was operated upon on 23rd November, 2015 in the Barwani Eye Camp and she was discharged on 25th November, 2015. 3-4 days later she started feeling severe headache, her eye became red and she started having acute pain. She could not sleep at night. She went back to Barwani Hospital, was prescribed a new set of medicines and sent back home. She revisited Barwani Hospital where a lady doctor said that she has high blood pressure and asked to take her to M.Y. Hospital in Indore. She landed at M.Y. hospital finally on 29th December, 2015. After reaching there, she was not given any attention whatsoever. For reasons unknown, she was never admitted to MY Hospital, nor referred to Sri Aurobindo Institute of Medical Science (SAIMS) for treatment. She continued going back and forth to MY Hospital for over a week. Rahisa is still suffering and has not got back normal vision. She has been left out of the list of 68 patients and has not got compensation or pension.
Naharsingh, son of Jamsingh, Nadia, Sendhwa: Naharsingh is only 40 years old. He has 4 children, his mother and his wife who are dependent on him. He had his cataract operation in the Barwani Eye camp. Almost 2 months later after the surgery, he still has not got back normal vision in his eye. He cannot see any further than 3-4 feet, his eye waters and he feels dizzy. Till now, he has paid 9-10 visits to Barwani and Sendhwa Hospitals. He has borrowed Rs. 2000 from the Anganwadi Worker of his village through which he’s managing the transport cost of visiting hospitals. For reasons unknown, he was not referred to Indore for treatment. He has not been included in the list of patients who have been sanctioned pension.
Detail of 19 patients who have not recovered their normal vision and were left out of the pension process by the Government
Our investigation team identified the 19 patients who were not referred to Indore and who were left out of the compensation/pension process. Our team located these patients in villages of Sendhwa, Pansemal and a few more Tehsils. Following is a high level status of these patients. Most of them cannot see far, have water falling from their eyes redness, and have hazy vision. Clearly they have not got their eye sight back and are suffering from problems even after 2 months since the surgery.
Our investigation team identified the 19 patients who were not referred to Indore and who were left out of the compensation/pension process. Our team located these patients in villages of Sendhwa, Pansemal and a few more Tehsils. Click HERE for the the status of these patients. Most of them cannot see far, have water falling from their eyes redness, and have hazy vision. Clearly they have not got their eye sight back and are suffering from problems even after 2 months since the surgery.
There are discrepancies in the number of patients who were granted pension. The media published a list of 65 patients as per government press note. However, data published in the website of Department of Social Justice states that only 63 people were sanctioned pension.
Target based approach for Blindness Control
Carrying out bulk cataract operations through eye camps is a target based approach for blindness control. In the last 5 years, in the Indore-Ujjain division, a total of 88 people have lost their eye sights. This is as per government data; the actual number may be higher than this.
Maintaining all service delivery norms around drugs, operation theatres, surgery process, post-op follow-ups etc. in bulk camps can be risky if all guidelines are not strictly adhered to. The system should be able to support cataract surgeries as and when patients need it and not be driven by meetings targets alone.
Status of Compensation and Pension disbursal
The Government has ordered pension for 65 patients. There are discrepancies in the number of patients who were granted pension. The media published a list of 65 patients as per government press note. However, data published in the website of Department of Social Justice denote that 63 people were sanctioned pension.
The government has not published the list of patients who got compensation of Rs. 2 Lakh announced by the State Government. The administration should publish the list of patients along with confirmation that compensation and pension have been disbursed to them.
At least one member of each affected household should be provided means of regular livelihood. Free medical facilities should be provided to all affected families.
- All patients still facing problems in their eyes should be provided due treatment at higher levels till their condition is stable. All treatment cost and transport cost should be borne by the Government.
- The patients who are still suffering from various complaints but were left out of the pension and compensation process should be immediately sanctioned compensation and pension as they have fully or partially lost their eye sights.
- At least one member of family should get regular livelihood support.
- The Government should provide latest heath status report of all 86 patients.
- The Government should publish the list of patients who received compensations. As per our earlier demand, the compensation amount should be Rs. 5 lakh per patient.
- All investigation reports should be made available in the public domain.
- There should be independent enquiry into the procurement process of all medicines, injections, saline and other relevant products and items.
- Strict action should be taken against the offending doctors/medical officers/and other officers with involvement in the camp. Suspensions of Collector, CMHO and nodal officers of National Blindness Control Programme whosoever found guilty, may be ordered. All concerned State and District health and administrative officials should be investigated and due criminal action taken.
- Free Medical facilities should be provided to all affected families across all hospitals in the State
*Investigation team: S.R Azad, Rakesh Chandore, Kamal Avasia, Mohan Sulia, Shamarukh Mehra Dhara, Amulya Nidhi – Jan Swasthya Abhiyan; Medha Patkar, Devisingh Tomar, Bhagirath Dhangar, Rahul Yadav – Narmada Bachao Andolan; and Chinmay Mishra- Swasthya Adhikar Manch