September 30, 2021 4:45:44 am
The (retired) Justice DA Mehta Commission of Inquiry report has found multiple regulatory violations and hazardous practices at the two Covid hospitals in Gujarat where 13 patients were killed in fire accidents last year. “It was an invitation for disaster,” the report, tabled Tuesday in the Gujarat Assembly, said about Ahmedabad’s Shrey Hospital where eight patients died. It also added that emergency exits at both Shrey Hospital and Uday Shivanand Hospital in Rajkot were non-usable.
The hospital’s administrator and majority stakeholder, Bharat Vijaydasji Mahant, told the commission the windows of the hospital ICU were sealed “as per NABH (National Accreditation Board for Hospitals) guidelines”, but left no room for ventilation. Critical medical equipment were also in use beyond their life expectancy.
Forensic Science Laboratory official CC Patel submitted that four windows in the ICU ward, situated on the fourth floor, were screwed together and it was not possible to open them. The then Chief Fire Officer MF Dastur’s account states how the firemen had to break open window panes to disperse the smoke as they “couldn’t even see the fire due to black smoke that had engulfed the entire ICU” as they tried to enter it from the regular door. However, Mahant submitted that the sliding windows had to be screwed together “as per NABH norms to prevent an ICU ward from being infected with bacteria or virus”.
The commission, however, found Mahant’s claims unjustifiable. “…it is apparent that there is no guideline for screwing windows together so that the same cannot be opened in case of emergency… As the facts have revealed, there was no exhaust system in place in the ICU ward.”
Dastur stated that “combustible materials in the ICU ward” could have contributed to the rapid spread of fire. He also added the CCTV footage revealed that the ward attendants lacked training that led “to a minor accident evolve into a disaster”.
The report also found the hospital violated the disaster preparedness rules. “There was no emergency exit… There was neither adequate firefighting equipment inside ICU, nor protection available to patients from electrical defaults..,,” it said. Mahant, along with his family members, holds 86 per cent share in Shrey Hospital, a registered company. He informed the commission that the hospital last got its fire NOC in April 2019, and was valid until April 30, 2020. Thereafter, the hospital was not in a working condition but was made functional again on May 23, 2020. An effort was made to renew the fire NOC but could not due to the pandemic, Mahant said, before adding that the Centre extended the NOC validity for six months from March 25, 2020, because of the Covid situation.
An affidavit by Dr Manishkumar, an officer on special duty at AMC, said necessary checks were undertaken at the hospital at the time of requisitioning on July 27, 2020. While the hospital satisfied most of the 129-point Covid checklist of the health ministry, clarity was sought on five problem areas, including cross-ventilation and exhaust fans. The hospital was given 15 days to take remedial action. However, the accident took place before the deadline.
Chaitanya Shah, deputy estate officer of AMC west zone, revealed that while development permissions were granted in 1996, applications were made by the proprietors in 2012 and 2013 seeking regularisation of unauthorised construction/use under provisions of Gujarat Regularisation of Unauthorised Development Act, 2011.
This was in relation to the lack of sufficient parking space, owing to which the owner was asked to provide a deficit parking facility within 500 metres from its property. However, the owner could not get the land, following which he requested AMC to recover the deficit parking fee and regularise unauthorised construction/use under GRUDA 2011. Soon, Rs 93 lakh was recovered for regularisation of unauthorised construction/use for various construction measuring over 2,437 sq m. However, the original construction plan was modified and the nature of use was converted from residential to commercial and residential use. “There was change thereafter from residential use to hospital,” the commission noted.
Uday Shivanand Hospital in Rajkot
The commission, upon inspectiing the premises in the aftermath of the accident, found it did not follow fire safety guidelines. The emergency exit door was “closed and blocked” by medical equipment and paraphernalia, which the administration justified was done in a bid “to maintain temperature and ensure that air-borne virus, if any, does not escape outside.” The commission, however, did not find this explanation excusable, noting that the door has to be “easily accessible and openable by anyone,” and that the ICU cannot be treated as a storeroom.
Electrical inspector Manojkumar Hansaliya deposed that the ventilator manufactured by Rajkot-based Jyoti CNC that has been determined as the plausible source of fire might have had “defective wiring inside”. “This might have resulted in sparking leading to the oxygen passing through the humidifier catching fire resulting in a blast. It is also possible that continuous use of the unit may have resulted in more heat being generated in the internal wiring of the humidifier resulting in sparking,” he stated.
“Neither the National Building Code nor the NABH is directly applicable in the case, but they have been referred to and applied as advisory guidelines for coming to the conclusion that the hospital management didn’t follow the fire safety norms considering the report of the fire department,” Manoharsinh Jadeja, DCP zone 2 of Rajkot, told the commission.
Rajkot Chief Fire Officer I.V. Kher said there was a total lack of evacuation plan, fire signages, automatic sprinkler system required in a building having two or more than two floors, and a written plan regarding steps to be taken by the employees in case of fire. There was only one entry and exit gate on every floor.
While the hospital had informed the authorities that it had an underground water tank of 25,000 litres capacity, this was later found to be of only 10,000 litres capacity, along with an overhead tank capacity of 11,000 litres, which Kher said was “insufficient” for fire fighting purposes. This especially became relevant as when the fire NOC was granted in September 2020, the checklist filled at the time had stated the hospital’s underground tank capacity at 25,000 litres, while the column related to overhead tank capacity was left blank.
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