Re: [reprohealth_india] Re: [pha-ncc] serial maternal deaths - this time in Jodhpur
- Dear Narendra,
Yes, what about others who had been on the IV fluids? Can you send the updates?
SAarojiniOn Mon, Feb 28, 2011 at 10:50 AM, Narendra <narendra531@...> wrote:
Besides the deaths, we are trying to find why only women in maternity ward have died because of the contaminated IV fluid injection. What happened to others if they were also injected the fluid from the same batch. Owing to flurry of activities of police and others, it is taking some time.
On Mon, 28 Feb 2011 00:00:35 +0530 wrotePrayas,
deaths in Jaipur: Police make first arrest, 2
Published: Sunday, Feb 27, 2011,
Place: Jaipur | Agency: PTI
Making the first arrest in the maternal deaths case,
the police today took into custody an official of an
Indore-based pharma company while Rajasthan government
suspended a drug inspector and a store keeper of one of
the two affected hospitals in Jodhpur.
mounting anger over the deaths of 13 women due to
excessive bleeding during childbirth allegedly after being
administered contaminated intravenous fluids, chief
minister Ashok Gehlot visited Umaid and MG hospitals and
made a bid to calm the situation. Gehlot hails from
government increased the Rs one lakh compensation
originally announced to Rs five lakh each to the families
of the victims, an official said today while announcing
the suspension of the area drug inspector Dinesh Taneja
and MG Hospital storekeeper Kusum Acharya.
police commissioner Bhupendra Kumar Dak said Sanjay Shah,
who is in the Production and Quality Control department of
Indore-based Parental Surgical India Limited, was arrested
with the help of the Madhya Pradesh police. "We have
arrested Shah and the team is taking him to Jodhpur for
the interrogation," he said.
said the government has also blacklisted the Indore firm
and Anshul Pharma, distributor for glucose supply.
decisions to make the suspensions and increase the
compensation were taken at a high-level meeting in Jaipur
last night presided by Gehlot who also directed the
Jodhpur Divisional Commissioner to probe thedeaths and
submit a report within 15 days.
At least 13
women have died in a span of 14 days between February 13
and 26 and three others are battling for their lives after
they were allegedly administered IV fluids in Umaid and MG
maternal death in Jodhpur hospital
Trust Of India
Posted on Feb 26, 2011
at 08:23pm IST
Jodhpur: One more
woman died on Saturday and four others were
battling for their lives after they were
allegedly administered contaminated intravenous
fluids in two government hospitals in Jodhpur,
where 13 maternal deaths have taken place in
last 11 days.
announced a compensation of Rs 1 lakh for the
families of the victims while the tragedy
prompted the National Advisory Council (NAC)
headed by Sonia Gandhi to seek an explanation
from the Health Ministry.
Bhavana, 27, died in
Mahatama Gandhi Hospital, where she had been
shifted from Umaid hospital on Sunday in a
critical condition following her delivery,
hospital sources said.
Angry relatives of Bhavana staged
protest at the hospital and refused to take the body.
They demanded that the compensation be raised to Rs 5
Minister and in charge of Jodhpur division, Rajendra
Pareek on Saturday visited the two hospitals and held
discussions with doctors and officials.
a compensation of Rs 1 lakh for the families of the
women, who had died of haemorrhage post-delivery after
they were allegedly administered contaminated
intravenous fluids supplied by an Indore based which
has been booked.
women, one in MGH and three in Umaid, are in serious
condition, the sources said.
committees which were probing the incident have
submitted their reports. While the six-member panel of
SM Medical College had blamed contaminated IV fluid
for the deaths, the two-member government committee
has suggested a slew of measures for the hospitals
amid fears that an infection could also have led to
four-member police team led by a sub-inspector was in
Indore to quiz officials of Parental Surgical India
Private Limited and carry out futher investigations.
A case was
registered under section 328 IPC (causing hurt by
means of poison with intent to commit an offence)
against Parental Surgical India Private Limited, and a
local distributor, for allegedly supplying the
contaminated I V
Pradesh health officials had on Friday raided the drug
hospital Superintendent Narendra Changani had said
that the administration has registered a complaint
against the manufacturing company and the local
distributor Anshul Pharam, who supplied the
contaminated stock of the I V fluid.
officer Dhagla Ram had said close to 10,000 bottles of
the IV fluid have so far been seized and a report of
FSL (Forensic Scientific Laboratory) is awaited.
precaution, we have kept the main operation theater
and labour room closed for fumigation," said principal
of the S N Medical College R K Aseri.
deaths: cases filed against pharmaceutical firm, distributor
Jaipur, February 26, 2011
Madhya Pradesh health
officials conduct searches on the drug company in
Cases have been registered against the manufacturer and
supplier of the suspected killer intravenous (IV) fluid
bottles in two major hospitals in Jodhpur — Umaid Hospital
and Mahatma Gandhi Hospital — after the deaths of 12
pregnant women in 10 days from February 13. The authorities
have seized 10,000 bottles of IV fluid from the stocks of
the Indore-based manufacturer Parental Surgical India Pvt.
Reports on Friday said the Madhya Pradesh authorities, on
the basis of information from the Rajasthan police, carried
out a search on the godown of the pharmaceutical company to
confiscate the remaining stock. The preliminary enquiries by
a six-member medical team, headed by Narendra Changani,
Medical Superintendent at the Umaid Hospital, indicated the
presence of fungus in the IV fluid.
Seven pregnant or newly delivered women, admitted to the
Umaid Hospital, and another five in the Mahatma Gandhi
Hospital, had bled to death reportedly after administration
of the IV fluid on them. Five more women are in a serious
condition in the two hospitals. The incident first surfaced
in the Umaid Hospital and some of the women admitted there
were shifted to the Mahatma Gandhi Hospital. However, the
Though the suspicion is on the IV fluid being infected, the
authorities are said to be critically examining the
condition of the labour rooms and the operation theatres in
these hospitals. The medical authorities are at a loss to
explain why the same IV fluid did not cause any death in
While the divisional headquarter city witnessed protests and
road blocks daily in the past few days, action against the
pharma firm and the local distributor sparked an agitation
by medical store owners and pharmacy suppliers.
8, Vijay Colony, Near Railway Station,
Chittorgarh 312 001
Tel : +91.1472.243788
Fax : +91.1472.250044
Sama- Resource Group for Women & Health
B-45, 2nd Floor, Main Road Shivalik,
- Dears Mira, Gita, Jasho and all others,This is indeed a very sad state of affairs.Please let me know if there is any way I can contribute/ lend myself to your efforts.With deep regards for all of you who are taking this fight forward.Dr Geeta Sodhi----- Original Message -----From: Mira ShivaCc: sama.genderhealth@... ; namhhr.india@... ; Aruna Kashyap ; coordinator@... ; firstname.lastname@example.org ; aditiyer@... ; Anuradha. SreevathsaSent: Wednesday, March 09, 2011 10:50 PMSubject: Re: [reprohealth_india] serial maternal deaths - this time in JodhpurDear Gita , Josho , Sarojini & friends ,
Just returned from Jodhpur . was part of the protest against Maternal Deaths , with this International women's day being treated as " Shok ( pronounced as in Poke) Diwas " Day of sorrow "for the 18 maternal deaths & their babies &many more .
From Geeta Bhawan the Rally led by Asha Vohra of Meera Sansthan Sashi Behan of Gravis , Usha of Vikalp left around 11 am . The organizers asked me to flag it off . The women many of whom were holding little babies marched up to Ummed Hospital , presented the demands , after heated discussion & questioning with the acting incharge .
From there rally went to Mahatama Gandhi Hospital , after long time gentleman incharge came to meet the women , over 400 in number . Demands were given after extensive heated discussions . kavita Srivastava joined the protest & from there led along with other organizers to Collectorate .
Since Collector was busy , later it was found that he had to go for lottery for Liquor contract or something related to it , women protested more vehemently . This being International women's Day .
The women blocked the road & after substantial time , 10-12 representatives were invited to discuss the issue . apparently rules for not lowing all rally members in & also not having collector come out to meet the rally was quoted . it was hot & there was ot even shade & water made available . Complaint which was made to the collector .
several demands were made
1Making case reports details available to the patient's families .
2Action against absent seniors , who left caesarians & hysterectomies to juniors .
3 Transference of staff as per Guidelines as some have been in same post for over 20 years , establishig private practice .
4 Action against overcharging of even women under JSY to the tune of Rs60,000 to R 1.50 Lakhs .
5Action against Attempt at cover up by announcing IV fluids as killers when none of the male & other patients given the IV fluids died .
6 Improving cleanliness of the hospital vicinity , wards , toilets etc
7Increasing number of skilled trained human power according to the patient workload , which has increased tremendously because of the Janani Suraksha Yojna related Institutional Deliveries . .8 Need to provide care for the New born babies & other children left motherless eg Bhawna who died has left Behind 3 baby girls 4yrold little girl , 2 year old & a 13 day old baby girl , with the father of children who was still in the mourning period needing to work outside home from morning till night for a meagre earning .
9 Strengthening Public Health services at the , one of the pregnant women who died in the village visited by sashi Tyagiji had died of Malaria , Malaria deaths in Pregnancy are not counted as Maternal Mortality , even though they are a cause of death of many pregnant women in endemic areas .
many of us who were involved in the 1995 Falciparum Malaria deaths in rajasthan affecting 4 districts Jodhpur , Bikaner , Barmer , Jaisalmer recall the large number of deaths estimated to be 4000
compensation for women who died from outside Jodhpur because of the same hospital induced infection & complications as women had come from far off villages .
A death of a pregnant woman with Malaria is a Maternal death & a maternal Mortality , even if it is defined differently & needs to be challenged .
10 Credible conduction of Maternal Death Audits & Maternal death Audit Reviews .
11 Stopping Private practice of senior doctors , there was evidence of repeated ordering of Sonography from Private diagnostic centres & prescription of drugs .
13 Rationalization of Medicine Procurement , Prescription writing .
the string of Private medicine shops & Diagnostic testing Labs outside the 2 Hospitals , are doing a roaring business & denial of quality care is one aspect of the problem, the exploitation of the poor, patients is really pathological . .
The Sasti sarkari Dawaiyon Ki dukans were there in both the hospital Ummed & Mahatama Gandhi but brands &prescribed by the doctors are not there
There were several other demands .
While at the 2 hospitals we saw many anxious & bewildered poor patients, men & women who had been given costly prescriptions , which these patients could not afford . One old man had been prescribed an antibiotic for cellulitis ,which he could not afford , he had been sent to collector's office to get a letter to say he was poor needing help in payment of medicines .
another man was limping around with wounds on his foot infected & oozing needing treatment & antibiotics which he could not afford .
An extemely anaemic & sick young woma patient leaning on 2 older women slowely shuffled out of the Hospital was put in an auto , with all 3 women in Ghoonghats . Tried to ask what was wrong repeatedly , but they looked sad & anxious & would not say a word
The issue is not just of the maternal deaths & maternal care which is affordable & of quality , but care for all those who are sick & with great difficulty manage to reach a" big "hospital , having knocked at the doors of subcentre & PHCs .
Maternal Death audit is not enough , there is a need for social audit & that too at multiple levels .
As we were leaving we were called back as one more death had taken place post hysterectomy, from Bleeding . She was not pregnant , but the need to find whether it was an avoidable death was important .
6 committees have been set up Centre , State , Internal etc etc . , media has been covering the issue doggedly , the Collector says he will ensure that some of the demands are met . The lady SDM has been assigned regarding follow up .
Obviously urgent change is required at many levels , the increasing comercialization of Medical Care on one hand & collapse of systematic downward trend of Public Health services is blatantly obvious . specially in the periphery where even the role of Dai has been stamped out , without ensurig of gender sensitive , easily accessible , affordable , quality maternal & health service , specially services ensuring safe pregnancy, safe childbirth & most importantly Post natal Care to the mother & neonate
. most of the women died of bleeding , most were anaemic . the presence of DIC Disseminated Intravascular Coagulation in 3 , fever etc is indicative of Infection , definately IATROGENIC infection .
What was the source of infection may come out in the reports by the State & Central Team as they had access to case records etc .
The Action that gets taken to prevent even a single preventable death in the future is the most important . not just in Ummed Hospital , Mahatama Gandhi Hospital or in in any hospital in Jodhpur , Rajasthan , but every village , every part of our country .
the fact that needless maternal deaths continue like this is reflective of much deeper pathologies , which need to be confronted .
The fact in each & every case where these young mothers died the husbands & families ,spent whateverthey could , took loans , paid through their nose & still lost their wives & mothers of their babies , which makes it sadder still .
It should really not be allowed to go on like this .
From: Gita sen <Gita@...>
To: email@example.com; Narendra <narendra531@...>
Cc: sama.genderhealth@...; namhhr.india@...; Aruna Kashyap <kashyaa@...>; coordinator@...; firstname.lastname@example.org; aditiyer@...; Anuradha. Sreevathsa <anuvathsa@...>
Sent: Mon, March 7, 2011 4:13:37 PM
Subject: RE: [reprohealth_india] serial maternal deaths - this time in Jodhpur
Dear Narendra and all,
From our experience of doing many verbal autopsies, it is very important to have an independent doctor on the team, but also to have a trained person interviewing the family and other community members.
We have been arguing for some time that after JSY has started, the institutions are the real weak links in the chain. I am not at all surprised that you did not find contaminated IV to be the cause of death. There is probably a set of different biomedical reasons for each case, most of which can be traced back to weaknesses on the services side.
We can try to provide whatever long distance support we can in getting to the bottom of this. If you need my team’s help, let us know.
Centre for Public Policy
Indian Institute of Management
Tel: +91 80 2699 3076
Fax: +91 80 2658 4050
From: email@example.com [mailto:firstname.lastname@example.org] On Behalf Of Jashodhara
Sent: Thursday, March 03, 2011 11:57 PM
Cc: sama.genderhealth@...; email@example.com; namhhr.india@...; Aruna Kashyap; coordinator@...; firstname.lastname@example.org
Subject: [reprohealth_india] serial maternal deaths - this time in Jodhpur
Thanks very much for sharing the findings from your first visit.
I am unable to see a pattern of causes in the list of deaths since I am
not a technical person, hopefully Chinu, Mira and others will comment.
The mystery of why IV fluids were immediately labelled /announced as the
cause of death is another conundrum: who made this instant diagnosis and
The costs you mention are shocking, but our earlier studies with JSY
have indicated similar expenditures especially for complicated cases.
The question now is, what should be our strategy: Should another civil
society team go in and complete the verbal autopsy for the other women?
Can we expect the government to present its maternal death enquiry findings?
Hoping to hear more thoughts on this,
On 03-03-2011 1:30 PM, Narendra wrote:
> Dear Jashodhara, Sarojini & friends:
> Kavita Shrivastava, Meeta Singh (Dr.) and I went to Jodhpur to
> investigate on maternal deaths happened in the tertiary (Medical
> College) hospital of Jodhpur. We did maternal death audit of four women
> by using the format prepared by Kirti Iyengar (Dr.)by modifying the
> usual one to be relevant for the tertiary hospital deaths. Sharad
> Iyengar was available on phone.
> This is the second biggest hospital of Rajasthan and is in the
> constituency of the present Chief Minister of Rajasthan. It is the same
> hospital where about one and half years back, six children of
> Thalessemia were infused HIV infected blood and 15 others suffered from
> The district administration provided a list of 14 deaths which took
> place between 13th February 2011 till 27th February 2011. Three more
> deaths have been reported since then. Please find attached the list of
> 14 women who died. The list has information about the date and time of
> admission, date and time of delivery (vaginal or LSCS), date and time
> of re-operation (hysterectomy), date and time of death, diagnosis and
> causes of death. I am also attaching the audit proforma we used to get
> information on chronology of events from the husband/attendants of the
> deceased women. We could do only four audits in one day. Out of them
> three had LSCS and one was admitted after her normal delivery
> elsewhere. Preliminary analysis shows that it is unlikely that these
> women died owing to infusion of contaminated IV fluid. We are not
> counting the woman (for time being)who delivered outside and had no
> LSCS because its possible that she was brought in very fatal condition.
> LSCS and re-operation was performed on others. Most common cause of
> death has been DIC, Hellp Syndrome, Septicemia and so on.
> The questions still unresolved and we are trying to analyse. We need a
> guidance of a good physician for this:
> 1. What is the link between DIC and contaminated IV fluid infusion?
> 2. In how much time contaminated IV fluid could cause DIC?
> 3. How contaminated IV fluid infusion led to PPH because in some
> instance it seems to have happened within few hours and in others, it
> took days.
> Our cursory understanding (Kirti, Meeta, Sharad and I) is that deaths
> do not have link with contaminated IV fluid infusion because then why
> only these women died and not others who are given the same fluid. We,
> as yet do not know that how many others were given IV fluid (trying to
> get under RTI by invoking clause of life and liberty). It is a common
> practice in medical college hospitals that women who deliver normally
> are also infused IV fluid. We will share more details about it soon.
> But please help us in understanding the link between DIC and
> contaminated IV fluid.
> Secondly, these deaths show that JSY is a complete failure. Relatives
> of all these patients spent roughly in the range of INR 50,000/- to
> 2,50,000 for treatment. Injections, some of which costed INR 6000 per
> ampule were asked to be bought.
> Thirdly, there are disproportionately high LSCS done in the hospital
> under investigation.
> Women's groups of Jodhpur have decided to organise a protest rally on
> 8th March on this issue. Those wish to join, please contact Kavita.
> More later.
> Best regards.
(Ms) Jashodhara Dasgupta