Lokayukta Justice Kanade satisfied with action taken in Bhandara fire

Mumbai Maharashtra’s Lokayukta Justice V M Kanade has partially accepted the report of the fact-finding committee in the Bhandara Hospital fire where 10 newborn infants died in the care unit on January 9, 2021.

Justice Kanade is satisfied with the suspensions, terminations and transfers of those responsible, but has asked for immediate completion of fire-fighting measures in all government hospitals, recruitment of engineers to maintain all machines.

The then acting Lokayukta Sanjay Bhatia had taken suo motu cognisance and initiated an inquiry. On November 7, 2022 the principal secretary of the state public health department Sanjay Khandare arrived before the Lokayukta for a hearing along with Dr. Nitin Ambadekar, additional director of state health services.

A fact-finding committee was headed led by Sanjeev Kumar, the then divisional commissioner, Nagpur and others. Based on their report, 20 witnesses were asked to depose before the committee. In order to arrive at the conclusive facts and the scene was recreated.

It was also found that building plan approval with fire NOC was not taken from the local fire service. The medico electronic equipment, fire medical equipment was also examined.

The contract entered into the service provider M/s. Faber Sindoori Management Services Pvt. Ltd. was examined and it was found that the technicians engaged by the firm had not received any machine-specific training with regards to servicing and maintenance of the radiant warmer and photo therapy unit.

During the inquiry, the fact-finding committee said that they did not have the service manual or electrical circuit diagram of the machines.

The CCTV surveillance system was not functional and electrical audit had not been carried out periodically.

Only seven infants from the newborn unit could be saved. In the forensic report, out of the 10 infants, three infants died due to shock and burn, while remaining seven infants died of suffocation

The report says that that the fire started due to the radiant warmer put on the baby trolley No.8, which had a defective electric circuit and some was caused on account of oxygen concentration present in the SNCU department and plastic materials was placed there.

The Lokayukta has asked the public health department of the government to ensure that sufficient training be given to these engineers and technicians engaged all over Maharashtra in maintaining all medico-technical equipment.

General hospitals should have a full-time electrical and civil engineer, the order stated.

The interim order states that Dr Pramod Khandate, district civil surgeon, Bhandara was suspended, Dr Sunita Badhe, additional civil surgeon handed a non-executive posting. Dr. Archana Meshram, head of Special Newborn Care Unit (SNCU) was also suspended.

Jyoti Bharaskar, sister In-charge, who was responsible for supervision and monitoring of SNCU was also suspended. Services of contract nurses Smita Ambilduke and Shubhangi Sathavane were terminated.

“I am satisfied with the action taken against the staff, but I want fire audits and measures to be taken in all hospitals,” Kanade said.

In the report, a chart showing fire audit information was annexed. In some of the districts, NOC has been received with respect to fire safety works, which are completed namely Kolhapur, Jalna, Nashik, Bhandara. While in other districts, NOC of the completed work is not fully received. Similarly, infrastructural changes have been made throughout Maharashtra.

He submitted that budget has been sanctioned for the said work. He further submitted that it will take some more time for completion of the said work, which has been taken throughout the State of Maharashtra. The next hearing will be conducted on January 24, 2023.