Twelve days after a fire killed 10 newborns at the Bhandara District General Hospital, the Maharashtra government suspended the district’s civil surgeon, Dr. Pramod Khandate, on Thursday, along with the hospital’s on-call physician, the Dr. Archana Meshram, and the sister in charge, Jyoti Bharaskar.
While additional civil surgeon Dr. Sunita Bade was transferred, the contract of pediatrician Dr. Stuti Ambade and two staff nurses, Smita Sanjay Ambil Duke and Shubhangi Sathavane, was terminated.
“The district’s civil surgeon and medical officer will remain suspended until the departmental investigation is completed,” Public Health Minister Rajesh Tope told The Indian Express.
The decision comes a day after Nagpur Division Commissioner Sanjeev Kumar submitted an investigative report on the fire incident to Health Secretary Dr. Pradeep Vyas.
Kumar headed a six-member committee that investigated the flaws that led to the Bhandara hospital fire. The fire had occurred between 1 a.m. and 1.30 a.m. on January 9.
The committee has held civil surgeon Khandate and additional civil surgeon Bade liable for negligence and lack of hospital maintenance.
The report held Khandate responsible because he was the general supervisor of the hospital and responsible for repair and maintenance work. The two were also responsible for ensuring adequate staff for the hospital.
The report indicated that duty nurses Duke and Sathavane were not at their nursing station at the time of the fire. The sister in charge of the Sick Newborn Care Unit (SNCU), Bharaskar, was held responsible for not ensuring that nurses were present at the nursing station.
Meshram physician and pediatrician Ambade have been held responsible for not being present at the SNCU at the time of the incident, although they were on duty there.
At the time of the incident, both nurses had left “to complete some report” after feeding all the babies. Meshram, stationed in the ward, treated patients in another ward. Ambade was also not present there, according to the report.
The two nurses rushed back only after hearing the first blast from a radiant heater. By then, a seven-day-old baby had charred to death in the exploded heater, the report added.
The report further said that the fire started in a warmer control panel radiating after a spark. The voltage fluctuation is suspected to have caused the spark.
The driver at the control panel was worn, the report adds.
The fire spread through mattresses and plastic in two other heaters. It melted the central oxygen pipe that runs through the roof and the SNCU wiring. This caused a great deal of smoke. Seven of the 10 babies in the SNCU’s “outbirth section” died from smoke inhalation and suffocation. Three babies died from burns, according to the forensic report.
The research committee recommended that trained electrical and biomedical engineers be appointed to handle electrical equipment and appliances in the hospital.
Tope said that this recommendation will be implemented. “We have also told the private agency Faber Sindoori to be vigilant in the inspection of biomedical equipment,” he added.
Faber Sindoori has been engaged for the maintenance of biomedical equipment in government hospitals in Maharashtra since 2017.
Additionally, the report has raised concerns about the need for proper coordination between the public works department and the health department to maintain all the hospital buildings. “I have written to all district guardian ministers to provide funding from the District Planning and Development Council for audits and repairs in hospitals. In the coming days, we will see several changes, “said Tope.
A fire audit is already underway in all government hospitals. In fifteen days, the districts will present a proposal to install more fire safety systems.
Tope said that CCTV cameras will be installed in hospitals and that the National Building Code guidelines will be followed for future construction and maintenance of hospitals.
Bhandara Hospital was allocated Rs 1 crore to carry out the repair of the damaged SNCU. The hospital began operation in 1981 without a certificate of no objection (NOC) from the fire department.
In 2015, when the hospital built an extension to open SNCU, a medical store and a nutritional rehabilitation center, for the second time the NOC was not obtained from the fire department.
While members of the investigation committee have raised concerns about who is responsible for granting such permits, Tope was silent on whether PWD will be responsible.
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