Chamarajanagar tragedy due to oxygen shortage: HC Panel
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Chamarajanagar tragedy due to oxygen shortage: HC Panel

May 13, 2021
  • Toll could be more than 24, says Committee in its report to Karnataka High Court
  • Slackness, callousness and mismanagement of oxygen supplies led to loss of precious lives 

Bengaluru: The three-member Committee of Karnataka State Legal Services Authority appointed by the Karnataka High Court (HC) to probe the Chamarajanagar District Hospital tragedy stated in its report that all the 24 deaths on the intervening night of May 2 and 3 occurred due to lack of oxygen. “Between 11 pm on May 2 and early hours on May 3, there was absolutely no oxygen at the Hospital attached to Chamarajanagar Institute of Medical Sciences (CIMS),” the report stated. 

The Committee, headed by Justice A.N. Venugopala Gowda and Justice K.N. Keshavanarayana, retired Judges and S.T. Ramesh, retired DGP&IGP, submitted its report to the High Court after analysing official records that were seized — from the Offices of Deputy Commissioners of Chamarajanagar and Mysuru — by the Chief Secretary on the direction of the Court.

Recommends compensation 

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.

As soon as the High Court appointed the Committee, the State Government cancelled the probe initiated by it under the leadership of KSRTC Managing Director Shivayogi Kalasad. 

Fault in ‘Death Audit’

“Had the Hospital administration been vigilant, it could have had enough stock of oxygen by timely refilling cylinders from its suppliers,” the report stated. The Committee analysed the ‘Death Audit’, held by a Committee consisting of District Surgeon and four others where the Committee has concluded that only three persons died on account of lack of oxygen, while seven died on account of Hypoxic Brain Injury and 14 due to COVID-19.

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“However, the fact remains that all those persons were in-patients in the Hospital and they were in need of oxygen during the crucial time when there was no oxygen stock available in the Hospital. The entry in the case sheets ‘FiO2’ indicates that there was deprivation of oxygen to them also during that period which resulted in damage to the brain cells of a large number of them and for other damage to their vital organs which might have led to their deaths subsequently,” the report said.

No mention of oxygen shortage

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. It 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. 

Toll higher than 24

The report observed that the toll due to lack of oxygen could be higher than 24. It noted that 62 died in the Hospital between May 4 and 6.15 am on May 10 and at least 36 were in-patients on May 2. “The death of these 36 in-patients could be attributed to non-availability of oxygen supply during the night of May 2 and early hours of May 3,” the report said. 

“The Hospital was dependent on six kilolitre liquid medical oxygen (LMO) tank, commissioned only on Apr. 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 process of jumbo cylinders was neglected 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.

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Mismanagement of life-saving oxygen

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 life-saving 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 am 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 am on May 3.

It may be recalled here that during a hearing of Chamarajanagar tragedy, the same Special Division Bench had noted that buffer oxygen stock could have averted the tragedy.

Committee Recommendations

The High Court has directed the State Government to consider the following suggestions made by the Committee of Karnataka State Legal Services Authority:

Provide compensation to the family of the victims who died due to negligence of the District Administration

Providing minimum buffer stock of oxygen and vehicles carrying Liquid Medical Oxygen should mandatorily have GPS. 

One bottling plant in Mysuru city is non-functional. State will take immediate steps to revive the plant’s functioning.

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