Multiple lapses led to nurse’s death, finds AIIMS probe

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An AIIMS committee has identified several procedural lapses leading to the death of a 28-year-old staffer in childbirth, raising serious questions on the services offered at the country’s most prestigious medical institution.

The victim, Rajbir Kaur, a nursing officer, was admitted on January 16 for normal delivery. The labour was progressing well till 5am the next day when there was a sudden drop in fetal heart rate, necessitating emergency surgery. The probe committee, headed by Dr S C Sharma of the ENT department, found that an anesthesiologist was not present during the caesearean section operation. Instead, the job was performed by a junior resident (JR) who neither had the experience nor was trained enough to handle such a complicated case.

Sources said the JR gave general anesthesia to make Kaur completely unconscious when most caesarean sections are done under spinal anesthesia. He also intubated the patient improperly. Intubation is meant to maintain oxygen level during surgery. However, in Kaur’s case, “instead of trachea – the pipe that connects the mouth to the lungs – the tube was inserted into the food pipe”, a source said.

The child was stillborn and Kaur went into distress due to aspiration – entry of stomach material into the respiratory tract. The nursing officer also suffered a cardiac arrest. She was revived but then she remained in coma for three weeks before being declared dead on February 4.

The inquiry committee also found that the consultant-on-call of obstetrics and gynaecology – whose presence is mandatory – did not turn up for the emergency operation despite being informed. She has been issued a show-cause notice by the hospital while the senior resident (SR) of anesthesiology, who was on duty, has been dismissed.

A displeasure memorandum has been issued to the SR of gynaecology, who can complete his medical training but will remain unemployable at AIIMS in future. A warning has been issued to the JR of anesthesiology who prepared the patient for surgery but later left under pressure from the residents of obstetrics and gynaecology.

Though instances of alleged medical negligence at AIIMS are many, sources said, this is a rare case where institute has been forced to accept negligence and take stern action. Also, for the first time, institute has agreed to pay Rs 10 lakh as compensation to the next of kin of the nursing officer and assured a job to a family member on compassionate grounds.

Dr K K Aggarwal, president of the Indian Medical Association, said the responsibility of consultants too should be fixed in case of procedural failure. “Residents cannot be blamed solely for such lapses,” he said.

V Srinivas, deputy director (administration) at AIIMS, has ordered the head of anesthesiology to ensure consultants from his department are available round-the-clock to oversee and supervise anesthesiology services. The panel also directed the setting up of a committee under the chairmanship of the hospital management to augment health services to AIIMS employees.

Two years ago, the son of an AIIMS employee had died at the hospital during dengue treatment. Five senior residents tendered their resignation after an inquiry report found lapses.

“Overall, we are satisfied with the AIIMS decision. But a meeting is planned with Union health minister J P Nadda to discuss certain issues,” said Manish Behl, husband of Rajbir Kaur.

“The lapses found in Kaur’s case have dented AIIMS’ image as the most prestigious medical institution in the country. If this is how the institute treats its own staff, god knows what happens in case of ordinary citizens getting treatment,” said a senior doctor at the institute.