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KILLING CLINICS : Where patients are prescribed death

Pitiable public health service has left people at the mercy of costly and careless treatment of profit hungry private hospitals and clinics. What dangers do that pose and how is the issue being tackled? Can we trust our medical system, or are the very places that are supposed to save us a threat to our lives? -RAMU SAPKOTA: CIJ

Cij Nepal

May 2, 2014

KILLING CLINICS : Where patients are prescribed death

Pitiable public health service has left people at the mercy of costly and careless treatment of profit hungry private hospitals and clinics. What dangers do that pose and how is the issue being tackled? Can we trust our medical system, or are the very places that are supposed to save us a threat to our lives?

-RAMU SAPKOTA: CIJ

For Releted New(Editorial): http://www.myrepublica.com/portal/index.php?action=news_details&news_id=73969

Careless treatment, manipulated reports

Nilisha Karki was only 20 years when she died of blood transfusion error at Kathmandu’s Nobel Hospital in the spring of 2013. Nilisha was diagnosed with Idiopathic Thrombacytopenic Purpura (ITP), a kind of disorder resulting in unusually low levels of blood platelets, at Kathmandu’s Institute of Medicine (IOM) Teaching Hospital.

In April 2013, Nilisha was taken to Grandee Hospital in Kathmandu which referred her Nobel Medical and Research Centre, where she was put under the supervision of hematologist Dr. Vishesh Poudel. After two weeks of treatment Nilisha was discharged, but three days later she came down with a fever and

breathlessness, she developed spots on her skin and her stool turned black. She was immediately admitted back in to Nobel Hospital. Even after being informed of his patient’s condition, Dr. Poudel arrived seven hours late after her admission, only to realize that she needed to be replenished with rare O Negative blood. She went into coma minutes after mistakenly being transfused with O Positive blood and died moments later.

Nilisha's family filed a case at District Administration Office Kathmandu on May 19, 2013 demanding investigation into the case. But the hospital authorities put the blame on the family of the deceased. In its written statement to the District Administration Office (DAO), the hospital has claimed that the deceased was transfused with O positive blood at the emergency room with full consent of her relatives. Nepal Medical Council (NMC)'s Expert Committee Report sent to the DAO on November 7, 2013 states: "In case of unavailability of O Negative blood - with the life of the patient at grave threat without transfusion - there is no harm in transfusing O Positive blood." However, NMC report lacks expert opinion on the matter. What is even more interesting is, there are only two specialists in Nepal who can make expert opinion on the matter, one being Dr Poudel himself. The other expert Dr. Ajay Kumar Jha told CIJ, that transfusing a patient with O Negative blood with O Positive blood under any medical grounds could prove fatal.

The hospital's records show that the patient was admitted to the emergency room at 10:30 AM on 1 May. Her hematology report issued at 12 noon showed her platelet level at 7000/µm, the normal range being 150,000/ µm (see pic).

According to the hospital report sent to the DAO on May 24 by Santosh Mani Neupane, director of the Nobel Hospital, Nilisha died in the ICU at 8 PM on May 1. Even the death certificate issued by the hospital with the signature of Dr. Poudel states the time of death as 8PM. However, hospital’s internal medical report prepared by Dr. Poudel states that Nilisha died at 4:25 PM and the hospital obtained written approval for transfusion from her parents only at 4:30 PM, evidently to put the blame back on the family as they ultimately did. (See the three conflicting reports)

Expendable lives

On 11 May 2011, four year old Dikesh Bajracharya, lost his life due to a sheer negligence of an on duty nurse at Lalitpur’s Patan Hospital who removed oxygen pipe from the child under intensive care, without consultation from the doctor. The hospital administration had accepted its fault in the case and promised action against its staff (see pic). However, it has backtracked since and denied responsibility in the matter.

Dikesh’s father Deepak had filed a complaint with the Lalitpur District Office seeking compensation and action against Patan Hospital, but four years on, no action has been taken and the case has been conveniently forgotten, as if it never happened. The family even complained to Nepal Medical Council but the council refused investigation citing lack of post-mortem report. ‘The hospital told us post-mortem was unnecessary since they were willing to accept the negligence and gave us in writing, but now NMC has refused to intervene in its absence. We have been cheated.’, says bereaved father.

After contracting fever and diarrhea, 3-year old Nischal was taken to Ratna Hari Memorial Hospital, in Tanahu district, early on 25 August 2013. When efforts to improve patient’s health with preliminary treatment failed, the doctor on duty Ram Kumar Shrestha ordered the nurse to inject the child with Diclofenac. Within minutes after injecting 3 ml of diclofenac, the child's condition began to deteriorate; his kidney and liver were failing. Unable to stabilize the patient, the hospital immediately referred him to Gandaki Zonal Hospital in Pokhara. The child was declared dead on arrival at 10.45 AM same day.

Doctors at the Gandaki Zonal Hospital say that the deceased was injected with medicine that should never have been administered. When Nischal's father Ramesh demanded a post-mortem, Kaski District Police Office turned him down deeming it unnecessary, as the cause of his death had already been determined. Ramesh lodged a case with the Nepal Medical Council(NMC) on September 6, 2013.

On October 23, 2013, District Health Office (DHO) replied to DAO Tanahu’s enquiry stating that Diclofenac was a non-steroidal anti-inflammatory drug which was safe for administering on children (see pic). ‘The deceased had been administered Azithron and Metron at Damauli’s Bhandari Medical Clinic. He arrived at the hospital weighing 12 kg, with his oxygen level at SpO2 77 percent. He was given 10 ml Flexon to control fever and 0.5 ml Diclofenac to counter his pain.’, DHO statement quoted Dr. Shrestha saying.

The medical investigation report on the deceased patient shows that his blood was infected and the patient had kidney and liver problems. Medical experts say, injecting diclofenac on patients with kidney or liver problems could prove fatal. Pediatric surgeon Dr. Gehraj Dahal says, children are not administered Diclofenac except in rare cases where reason is clearly stated.

After lot of difficulties, on September 25 last year Nischal’s father Ramesh managed to get the Health Ministry to issue a letter instructing Western Regional Directorate to investigate Nischal’s death . However, Dr. Ashok Kumar Chaurasiya, the Directorate head, says he has yet to get a response from the DHO although the later says it has already sent its report. Even a letter sent from the other cornor of the globe arrives within a week, but in this case it has been six months and we are still counting.

‘I lost my son, and now they are adding insult to injury with their insensitivity in the case.’, says dejected Ramesh.

Lalitpur Lamatar’s Krishna Prasad Pokhrel had an accident on the morning of April 11, 2013 and broke three rib bones while a bone got bent. After applying vapour therapy for a week, Pokhrel started treatment with Dr. Kishore Lal Shrestha in Kathmandu’s Alka hospital, who prescribed him Bestocef CU antibiotic tablet (See full list of medicines prescribed) for a month. On the fifth day of his medication, Krishna’s nose began to bleed and there were traces of blood in his stool as well. The doctor asked him to discontinue the antibiotic but continued other medicines.

On the fifteenth day, Krishna was admitted to the Tilganga Eye Hospital after developing blurred vision, from where he was referred to Dr. Rabindra Shrestha at the Kathmandu Medical College(KMC), Sinamangal. Pokhrel's sclera had developed a wound, his pupil had shifted to the left and the sugar level was out of the normal range.

Pokhrel was prescribed medicines without a thorough check-up, mandatory for patients above 40 years old. Further tests showed that Krishna’s kidneys were damaged, and all the while he was on antibiotics! It is a common medical practice to avoid prescribing antibiotics to patients with high sugar levels and kidney and liver problems. Besides, people with bone injuries are prescribed medications only after ascertaining their blood pressure and sugar levels. Dr. Shrestha had carelessly prescribed medication to Krishna without determining his condition which cost the patient his vision.

Krishna filed a complaint with the hospital director demanding action against the careless doctor. However, the hospital administration tried to hush the matter down by arranging for a repeat check-up. After the check-up, Krishna was told that his eye problem was caused by severed vein at the back of his neck. This alarmed Pokhrel who then petitioned the National Human Rights Commission (NHRC), NMC and the Kathmandu DAO. The latter sent his petition to the DCC which denied a hearing citing petty procedural shortcomings.

Blaming the victim

Mukesh Kumar Upadhyay of Morang, went to Jawalakhel’s Alka Hospital with a complain of joint pain on September 18, 2012. After initial investigation and a CT-scan, Dr. Pushpa Malla prescribed him medicine for TB. Normally, a sputum PCR Monteux test needs to be conducted before diagnosing TB; which had turned positive for Mukesh a month back. However, Dr.Malla who also heads Nepal Anti-Tuberculosis Association (NATA) did not even feel it necessary to follow this simple procedure.

On the very next day of taking medication, Mukesh started from itchiness, rashes in his skin and insomnia. Alarmed, he went back to Dr. Malla who assured that the side-effects were normal and advised him to consult a dermatologist. She also gave him anti-TB injection and told him to contact NATA’s DOTS (directly observed treatment, short-course) clinic in Morang.

Further tests at clinic confirmed that he had no TB microbes. However, Dr. Malla insisted that Krishna continue on her prescription which resulted in him contracting jaundice two weeks later. His skin had turned black and cracked, and his body began to swell causing difficulty in breathing.

Mukesh’s family rushed him to Medanta Hospital in New Delhi. The doctors at Medanta diagnosed 'medicine reaction' and tests there confirmed that he had no TB (see pic) . Mukesh had to undergo operation to overcome damage caused by TB medication on his kidneys.

After he came back from Delhi, Mukesh petitioned the DAO Morang demanding action against Dr. Malla which then reffered the case to DAO Lalitpur. He also filed his complain at NMC and the National Consumers’ Forum. Lalitpur administration initiated the inquiry and referred Mukesh’s case to District Compensation Committee, which surprisingly put the blame on the victim demanding to know why the petitioner hadn't consulted the hospital before going to Delhi for treatment. ‘After such careless treatment, who would want to risk his life continuing treatment at the same place? DCC did not take our plight into consideration. Had I waited for the hospital’s approval, I could have died.’ laments Mukesh.

The Consumer Forum was of no help either. A consumer activist called him and instead tried to fork out money, apparently for expenses to conduct press conference and media lobbying.

Denied Justice

Anita Karki (Nilisha’s Mother)

We petitioned the DAO for investigation into my daughter's death on May 19, 2013. The DAO summoned us at regular intervals while awaiting the Expert Committee Report of the NMC but we were shattered when the report stated that the attendant doctor wasn't at fault. Even the District Compensation Committee bought into this white lie overlooking hospital’s internal documents that reveals, they made us sign the approval papers after my daughter had died in ICU only to save themselves. Most unfortunately, the committee reached its conclusions without convening a single meeting between us, the doctor and the hospital.

We weren't hankering for compensation. All we wanted was justice for my deceased daughter, and punishment for the doctor responsible for her death. But it seems, justice is a privilege that common citizens cannot afford in this country, and investigations are but a smokescreen to shelter the high and the mighty.

NMC is blind-eye to illegal medical practice

Dr. Satish Deo

Coordinator, Ethical Committee

Nepal Medical Council

NMC has the mandate to oversee the standard of medical practices and ensure that medical practitioners adhere to its prescribed code of conduct. It is an autonomous body which functions under direct instruction of the Health Ministry. So far, the body has failed to sufficiently live up to its mandate. Whether this is due to external intervention or sheer unwillingness of those working here, I cannot say for certain.

Every qualified medical practitioner, local or foreigner, has to register with the council before starting the practice or any health related program of any duration. Failing to do so gives NMC authority to take action against the concerned. However, it is disappointing that NMC has been ineffective in preventing unregistered and illegal hospitals and clinics from running their operation across the country.

In December last year, an Onocologist resigned from B & B hospital in Lalitpur’s Gwarko. The hospital then hired an Indian specialist who has been practicing illegally without being registered or obtaining permit from the council. Who will be responsible if there is a loss of life at the hands of an unlicensed doctor?

So, you see, a private hospital has hired a doctor who is practicing illegally and this is not happening in secret. Yet, the monitoring body is unable to take any actions against the hospital or the doctor. What should we make of it?

[May 2, 2014, In Republica Daily]