Twenty-four COVID-19 patients, who were being treated at Chamarajanagar district hospital, died due to lack of oxygen on May 2 and 3, and the shortage of oxygen occurred due to failure of the district administration in general and the hospital authorities in particular, according to a report submitted by a committee consisting of two retired judges of the High Court.
“The Dean of Chamarajanagar Institute of Medical Sciences (CIMS) and the in charge district surgeon, a microbiologist, did not exhibit leadership quality and failed to efficiently marshal available resources to save lives,” the report said.
“The Deputy Commissioner of Chamarajanagar, as chairman of the District Disaster Management Committee, miserably failed to guide and supervise the crisis situation arising out of extreme demand for oxygen. On the contrary, he indulged in an unsavoury blame game accusing the DC of Mysuru of causing hindrance for oxygen supply without any basis,” the committee pointed out in its report. “...the DC, Mysuru, did not come in the way of refilling agencies in Mysuru from refilling oxygen cylinders of any other districts, including Chamarajanagar,” it stated.
The committee, comprising A.N. Venugopala Gowda and K.N. Keshavanarayana, retired judges, and S.T. Ramesh, DG&IGP (retd), submitted its report to the Karnataka High Court after analysing official records that were seized by the Chief Secretary on direction of the court. A Special Division Bench comprising Chief Justice Abhay Shreeniwas Oka and Justice Aravind Kumar directed the government to submit its response on the report of the panel, which has recommended payment of compensation to legal heirs of the 24 victims.
The report also said that a detailed probe is essential to unearth omissions and commissions of individuals.
“Had the hospital administration been vigilant, it could have had enough stock of oxygen by timely refilling cylinders from its suppliers,” the report stated.
Interestingly, the report pointed out that there was not even a whisper about shortage of oxygen stock at the hospital by any of the Mysuru-based agencies, with whom CIMS had contracts, in the meeting held by the DC, Chamarajanagar on May 2.
The report said the hospital was dependent on six kilolitre liquid medical oxygen (LMO) tank, commissioned only on April 29, 2021, though it was installed several months ago. Prior to commissioning of the tank, the hospital was using 250 jumbo cylinders along with 100 jumbo cylinders secured from taluk hospitals.
“Refilling of jumbo cylinders took a nosedive after commissioning of the tank. The mismanagement in that regard is quite evident. Slackness appears to have set in probably on account of LMO tank being installed,” the report said.
The report also pointed out that “oxygen in the LMO tank should have catered for a period of at least 40 hours. But it is reported to have been exhausted in less than 30 hours, which shows mismanagement of the lifesaving gas, even during critical time.”
“Had the hospital administration been vigilant, it could have had enough of oxygen by timely refilling of cylinders. With the bottling plant at a distance of about 70 km, not having sufficient filled oxygen cylinders at Chamarajanagar is an act of callousness and led to loss of dozens of precious lives,” the report said.
The report found that as the Mysuru district hospital dispatched 40 jumbo cylinders at midnight on May 2, the truck should have reached Chamarajanagar by 2 a.m. if it had not stopped anywhere. However, the truck waited for hours at a refilling agency to load another 30 cylinders and reached Chamarajanagar hospital only at 6 a.m. on May 3.