World Bank Funded Punjab Health Systems Corporation Hospitals Improved Services or Abetting Deaths A Case study of death of Thana Singh in Civil Hospital, Bhatinda Punjab Health Systems corporation World Bank (WB) gave a loan of US$106.1 million to state of Punjab for health sector reforms. The project was to be implemented by the Punjab Health Systems Corporation (PHSC). Before that the public health system consisted of three tiers and was managed solely by the state through the Department of Health and Family Welfare. The World Bank Group's Country Assistance Strategy for India supports broad-based, private sector- led growth. The World Bank funded Punjab Health System corporation (PHSC) was established in health sector of Punjab eroding the very foundation of the state responsibility to provide basic health care in perspective to right to health. The structural changes, one of which is charging user fee was introduced in WB funded PHSC. The objectives of the project were to improve efficiency in allocation and use of health resources through policy and institutional development, improve the performance of the health care system, increase coverage and effectiveness of services at the primary and secondary levels, and to better serve the neediest sections of the population. This loan of World Bank added further debt to the already broken back of the state. District Bhatinda The control and Management of Civil Hospital Bhatinda (100 beds ), Hospitals at Rampura Phul (50) Talwandi Saboo (50) Goniana (30) Sangat (30) Nathana (30) Bhagta (30) Bhucho Mandi, Maur Mandi(25) women's hospital Raman Mandi (10) and Children Hospital Bhatinda (100) was transferred to the corporation. Civil Hospital Bhatinda It is a 100 beds district level corporation hospital. It has a Emergency department, Intensive care unit, trauma center, Blood Bank, well equipped laboratory and operation theaters, specialist doctors including many Surgeons, Medical specialists, Pathologists, Gynecologists, Orthopaedicians, Radiologists and Forensic expert. Case Of Thana Singh One Thana Singh aged 30 years, s/o Bhola Singh resident of Dhanpura, Sirsa, Haryana, was brought to Corporation Hospital at Talwandi Saboo at about 1 noon on 5.2.2000. He had a gun shot wound in his right thigh just above the knee. He was admitted to emergency ward and police was informed at Talwandi Saboo by the hospital authorities. The pulse of patient was recorded as 86/min. Treatment given was Injection Fortwin, Inj Dextrose 5%, Injection Ampicillin and Inj Decadron. No Investigation was done. Patient was referred to Civil Hospital Bhatinda at 11.40 PM on 5.2.00 i.e. after about 12 hours of the admission at Talwandi Hospital . Talwandi Saboo is about 25 Kilometer from Civil Hospital (CH)Bhatinda. A private person and not police brought Thana Singh to CH Bhatinda at 1PM (noon) on 6.2.00. At about 7.30, attendant (Father in-law of Thana Singh) was allegedly told to shift the patient to higher institution. There were thumb marks of Thana Singh and his father- in- law on the file stating inability to take the patient, on page no.2 of the treatment file. No reasons were assigned as to need for referring him to higher institution. No authority under whose custody Thana Singh was, informed of the need to shift him to higher institution. . Thana Singh was shifted to deferred judicial custody while in hospital. On page no 7 of the treatment file, the examination of the patient at time of admission is recorded as G/E (General Examination) – Conscious, Pulse 90/min, BP 120/70, GC better. Treatment given is recorded as Inj TT, Decadron, Mikacin, Dolonex, Fortwin, and Phenergan. SMO (Senior Medical Officer) was informed. After that notes on the file show time at 7.30 PM. There is no record of condition between 1Noon and 7.30 PM. At this time Thana Singh was referred to DMC (A private medical Institute at Ludhiana) /RH PTI (government Teaching institute cum Hospital at Patiala). While referring neither any reason was assigned as to need of that nor any examination of vital signs or condition was done before reaching the decision to send the patient to higher institute after more than 30 hours of patient under treatment. No intensive treatment was given before that, which could indicate serious condition of the patient. No investigation was done till this time. All vital signs as recorded showed good physical condition. Notes in the treatment files (with one continuation file) were so haphazard that it becomes essential to note the chronological order of the time and dates. Here under order of time and dates of medical notes are noted : - Page Date Time 7 6.2.00 1 Noon 7.30 PM 8 14.2.00 7.30 PM (Thana Singh declared dead on 14.2.00 at 8.50 PM) 7.40 PM 8.00 PM 9 6.2.00 5.00 PM 6.2.00 nil 10 7.2.00 nil 11 14.2.00 nil 12 Pulse, temperature, respiration record of 6/2, 8/2, 10/2 and 11/2 without mentioning the time. 13 6.2.00 nil 6.2.00 nil 13.2.00 7.2.00 3.00PM 8.2.00 nil 10.2.00 14 10.2.00 11.2.00 10AM 14.2.00 8.10PM 15 ineligible date 12.2.00 14.2.00 7.00 PM 14.2.00 3.00 PM 14.2.00 5.00 PM 14.2.00 8.00 PM 16 14.2.00 5.10 PM 14.2.00 nil 21 14.2.00 8.15 PM 22 14.2.00 7.30 PM 14.2.00 8.10 PM 8.30 PM 8.50 PM Continuation file started, Page numbers 23, 24, 25, 26, 27, and 28 are blank. 29 14.2.00 nil 30 14.2.00 8.50 PM Investigation Team An investigation team was constituted of Mr. Ved Parkash Gupta, General Secretary PUCL (Punjab), Mr. Balwant Singh Dhillon, Senior Vice-President, Lawyers for Human Rights, Mr. B. S Bhuller, Journalist, Mr. Surinder Sharma Advocate and Dr. Vineeta Gupta General Secretary Insaaf International as convenor of the investigation team. The team met hospital authorities, doctors involved with the treatment, Senior Superintendent of Police and others. The team members studied the treatment file in detail. Observations The treatment record of the Thana Singh who was under Deferred judicial custody, screams of the utter negligence in treating him. At no step was he treated with care, diligence or expertise. The haphazard entries in the file clearly indicate the cover up procedure, that was attempted after his death. It appears from the record that he died not due to his injury but careless and callous attitude of the doctors treating him. An advice for referral to higher institution was noted in the records to escape responsibility. He was first kept at hospital at Talwandi Saboo for almost a day then referred to CH at Bhatinda without giving any reasons for referral. After the patient came to Bhatinda he was further referred to the higher institution, no reason was again assigned for doing it. At the time of advice for referral, patient had well maintained vital signs. When orthopaedician was asked as to the reasons for referring the patient, he could not give any satisfactory reply. The District Medical Commissioner informed the team that the hospital was 'fully equipped' to deal such types of injuries. With crores of debt burden the hospitals are 'upgraded' and medical equipment are purchased to make the services efficient. Even then a gunshot wound on thigh is referred to the higher institutions without much thought. More over his attendants were not authorized to shift him as he was under deferred judicial custody. No concerned authority was informed of the same. His output/-input chart was not maintained which is of extreme importance in such traumas and also if the doctors thought he was serious enough to be referred to higher institute. No examination was done from time to time. No record of his vital signs was kept periodically. On admission on 6.2.00 the general condition of the patient is recorded to be better and conscious but the patient was declared to be unfit for making statement to police by the emergency medical officer. And his Hb was maintained at 9 gm%, signifying that patient was not bleeding from his wound. Though at 3.00 PM on 14.2.00, it was recorded that there was complaint of hematemis and blood colored stools. But no efforts were made to ascertain the reason. No investigations were ordered to find out the cause. No where it is mentioned as to estimated amount of blood loss. On 14.2.00 at 4.30 PM a unit of blood was ordered to be transfused to the patient but no reason was given for giving blood. No examination was done. No signs and symptoms were noted down. BP is noted to be unrecordable while pulse is noted at 120/min on 14.2.00. No investigations except Hb, BT, CT and Blood group were ordered till 14.2.00 at 5.10 PM in hours of which the patient died. On 14.2.00 also only Hb, TLC, DLC, BT, CT, X-ray Chest, ECG, RBS and urine complete were ordered. The Results showed HB of 9 gms% on 14.2.00. MD Chest and Tuberculosis was called to attend to the patient as medical specialist when there are four MD Medicines available. It was recorded in the treatment file that patient had cardiac arrest. There is no record of cardiac status available though there are many cardiac monitors in the hospitals. No efforts were made to use defibrillator to revive the patient. It is commonly observed that cardiac arrest has always been a very favorite escape diagnosis. As usual there is no record of the pre cardiac arrest status of the heart despite well-equipped Intensive care unit with cardiac monitors etc. The orthopaedician who was main treating doctor, was one of the members of the board constituted for conducting the postmortem to ascertain cause of death. The board of three doctors included a Radiologist; Medical Specialist and the treating doctor while a forensic expert is available in the hospital. It is a common knowledge that patients and their attendants are generally advised for referral to higher institutes in papers, to escape any responsibility in case of death. No reasons are assigned for referring the patient. During the interviews with the hospital authorities it was also discovered that there is no criteria for referring the patient. There is no record as to how many patients are advised referral though there is record of how many are actually shifted. There is no active supervision by the health authorities. The office of the DMC is in the same premises but he informed the investigation team members that he was made aware of the case through newspaper reports and that did not know any details because he did not want to meddle in the affairs managed by Civil Surgeon. Civil Surgeon was co- operative and directed the senior medical officer to show the medical record to the team. Though the SMO made the record available for the team to read, but refused to answer any questions regarding treatment and management of Thana Singh or functioning of the hospital. Two parallel systems of state department and corporation have added to the already prevailing chaos in the health services. There is further deterioration of the health facilities. While implementing World Bank funded Punjab Health Systems Corporation over state run health services; real reasons for poor health services were ignored due to vested interests of both, the state authorities and WB authorities. It was Corruption, poor administration, favoritism, and faulty policies that were major contributing factors in badly run state health facilities. There is no effort of either the state or WB to check these, despite their claims to the contrary. Case of Thana Singh is not an isolated example. Patients seen as 'use less' ( in terms of illegal gratification) are treated in this manner. Lucky ones survive but the less lucky die like Thana Singh. This is a common practice in corporation/state run hospitals all over state. There is no review of deaths occurring in the hospital. Rather cover up operations, fully patronized by the authorities are under taken to protect the corrupt and guilty. Even a child on the street knows this truth, but the WB is fully 'satisfied' with the functioning of the Punjab Health Systems corporation Demands Immediate, time bound inquiry of death of Thana Singh by siting Judge. Responsibility be fixed and stringent punishments to the guilty. Review of all the cases that are advised referral. Record be maintained for such advice and reasons for it. Proper guidelines for cases to be referred. All hospital deaths to be reviewed critically by a committee of doctors with non- government representation in the committee. The record of such reviews be available to NGOs. Curbing of corruption with a heavy hand practically and not in speeches and papers alone. Bhatinda:- 20.2.00 Dr. Vineeta Gupta General Secretary Insaaf International Convenor, Investigation Team Punjab Government Gazette, Chandigarh Friday, October 20, 1995 OPD slip no 28 dated 5.2.00 treatment file, admission no 462 dated 6.2.00 Treatment file page I to 52 of Civil Hospital, admission number 462 dated 6.2.00 The Tribune, Desh Sewak dated 15.10.99 2 4