66 People Lost Eyesight After Being Operated

In Barwani District Hospital, Madhya Pradesh

Independent Investigation Report of Gross Violations of Cataract Surgery
Camp, jointly organized by Barwani District Hospital and Lions Club

Photo courtesy by Hemant Garg,Barwani

By Representatives of Jan Swasthya Abhiyan and Narmada Bachao Andolan-

17 December, 2015
An independent investigation was carried out by representative of Jan Swasthya
Abhiyan, Narmada Bachao Andolan and Swasthya Adhikar Manch into the serious
matter of a large number of patients losing their eye sights as a result of an eye cataract
surgery camp which was jointly organized by Barwani District Hospital and Lions
Club between 16th to 24th November, 2015, under the District Blindness Control
Programme, part of National Blindness Control Programme. A committee is formed
under the District Blindness Control Programme which is chaired by the District
Collector. This committee allocates budget to NGO-s for the camp and procures drugs,

injections, and other necessary items through state level tender, or local tender or
direct purchase under the guidelines set by the Government.
A total of 86 patients from Sendhwa, Silawad, Dhanora, Warla, Chachria, Balwadi,
Pansemal, Niwali, Piplaj, Ekkalwara, Kashta, and Dharamrai of Barwani and Dhar
district of Madhya Pradesh were operated upon in the camp.
Ringers Lactate solution was used during surgeries which is usually packaged in
plastic bottles and have probability to catch fungus. The particulars and quantity of
which pre-operative medicines, intra-operative medicines, and post operative
medicines were used is not known. Moreover, it is a matter of severe concern whether
these medicines were procured through State level tender or local tender or through
direct purchase.
After the operations, at the time of discharge, the patients were advised to visit their
nearest health centre for follow-up. Based on findings and interviews with patients and
their relatives, it is known that the patients were prescribed Moxicip Eye Drop
(Moxifloxacin), batch number C850127 of Cipla, Zoxan D of FDC Ltd, Atropine
Sulphate of Jawa Pharmacy, Biotin, Levofloxacin and Ibuprofen at discharge. The
question is where these medicines were sourced from centrally from Bhopal or
locally at Barwani.
On the 2nd-3rd day after the surgery, patients went to health centers/or to the district
hospital with complaints of burning sensation and pain in the eyes.
They were given injections and some medicines and were asked to return for followup. Some patients went to private hospitals and spent from their pockets for followups as the district hospital was far. The patients got no relief from their symptoms.
By 18th-19th December, similar multiple complaints of pain, itching and watering eyes
had started pouring in from the first batch of patients; despite that, surgeries of new

patients were continued. It is beyond comprehension as to why fresh surgeries were

continued even after knowing that things were amiss and earlier patients had caught
severe infections.
When the complaints became acute and widespread, most patients were asked to come
to the District Hospital where they were admitted for follow-up treatment. But none of
the patients got any relief from this treatment. Some of the patients were taken to a
private hospital namely to Dr. Rajendra Malviya of Sarswati Eye Hospital. As per
interviews with patients, it came to light that the letterhead portion of the prescription
of Dr. Malviya was torn off and the rest of the prescription was filed in the hospital file.
The investigators are in possession of sample copies of Dr. Malviyas prescriptions.
Following this, most of the patients were referred to Sri Aurobindo Institute of Medical
Science (SAIMS), Indore. Some patients were referred to M.Y.H. Hospital, Indore
where they were kept for a day, followed by moving them to SAIMS. It is questionable
as to why patients were referred to SAIMS instead of being treated at M.G.M. Medical
College attached hospitals despite MYH Hospital having adequate numbers of
ophthalmologist specialists of all levels.
According to Govt. rules, in case of emergency, patients should be referred from the
District Hospital to M.Y.H. Hospital attached to M.G.M Medical College. It is clear
from the patient case documents that they were referred to M.Y.H. Hospital. But what
is completely unclear is on what basis and on whose orders were they sent to SAIMS. It
is mentionable that SAIMS have been in the mid of controversy earlier. Around 3 years
back, the State Govt. had attempted privatization and wanted to shift M.Y.H. Hospital
to SAIMS under PPP model, in the guise of knowledge partnership. At that time, this
was stopped by sustained campaigns and collective effort of organizations, individuals,
medical fraternity and media.
Its not clear despite sending to a private setup, how many patients could save their eye
sight fully or partially.

At the time of referral to Indore, only few patients had lost their eye sights. After
getting admitted to SAIMS, the patients underwent repeated eye surgeries. During the
period the patients were in the district hospital or later admitted to SAIMS, out of 86
patients, 66 patients have lost sight of one eye completely. The condition of the
remaining 20 patients needs to be made public. The Govt. investigation team should
publish complete list of all 86 patients including their particulars, detailed condition,
whether any of them have recovered their sight, how much has been spent on each
patient by hospital management.
The first referral to Indore occurred on 3rd December, 2015 whereas infections were
reported by 18th-19th November, 2015 timeframe. What was the cause for waiting for
such a long time after the infections were confirmed? There is no clarity on how
infections erupted even today after almost one month has passed since the camp.
The Government investigation team has not yet disclosed batch numbers, quality test
reports, company names, and procurement detail of drugs, injections and fluids used.
These should be made available to the public immediately. The Companies from where
drugs were procured and beneficiaries of these companies or people who stand to
profit from of these companies should be disclosed.
The issue of supply of sub standard drugs throughout the State was raised earlier, but
government has not taken the matter seriously.
Case Study of Rashid Khan, son of Kaasam Khan
Rashid Khan came to the District Hospital of Barwani on 14th November,2015 for the
treatment of his eye. On the same day at 6 pm, he underwent cataract operation. He
was discharged on 15th Novemeber, 2015 from the hospital. Around 8 days later, he
complained of severe discomfort in his eye. He came back to the hospital on 24th Nov

and was sent back home after giving treatment. However, he got no relief. He went to
Dr. Malviya of Saraswati Hospital on 28th Nov and spent Rs. 200 on fee and Rs. 1400
on medicines. His bills are available. He got no respite from the pain and itching in his
eye. He was sent to SAIMS Indore on 3rd December, 2015. Rashid Khan has now lost
sight of his eye.
Case Study of Nania
Nania, son of Junga, from Village Kashta, Dharamrai, Nisarpur Block, Dhar went to
the house of Dr. Radhesham Palod on 18th Nov, 2015 for treatment of his eye. He paid
a fee of Rs. 200 fees and Rs. 2500 for cataract operation. His surgery was carried out
the next day at the eye camp in the District Hospital. After the operation, he was
discharged the next day. He started getting pain and burning in his eyes. He came back
to the district hospital on 28th November and saw Dr. Malviya on 29th November. His
symptoms did not change at all and he got no relief. He was sent to SAIMS on 6th
December. Nania has lost sight of his eye.
Major findings of the investigation
It is clear that infections had spread from the site of surgery and equipment
used during surgery.
Quality of drugs, fluids and injections used on the patients during and post
surgery are questionable.
Hygiene of operation theatre was compromised. This is noted in the whole
hospital in all wards and complaints were made by various organizations
earlier. It needs to be enquired whether separate sets of gloves, instruments
and materials were used for each patient.
Proper process of follow-up by doctors/medical team/hospitals was not
done, such as centralized and timely checkup in the district hospital.
Timely identification and treatment of infection did not happen.

 That it was carelessness and casual approach of the eye surgeons and
support staff as well as from CMHO and Collector that led to continuation of
operation without action even after the first batch of patients returned with
various complaints and infections.
Peoples Demand
1. Patients should be treated at the higher level and their eyes should be
replaced without delay. If required, they should be immediately sent to
higher referral hospitals outside the State.
2. Patients, who have definitively lost their eye sights, must get due
compensation. Victims, who were earning members of families, should
receive higher compensation. Non-earning members should receive regular
pensions.
3. State should issue order for high level independent enquiry into the whole
matter. Enquiry should cover all drugs, fluids, equipment, and medical
process.
4. There should be enquiry into the procurement process of all medicines,
injections, saline and other relevant products and items.
5. Strict action should be taken against the offending doctors/medical
officers/collector/and others involved in the camp. Suspensions of Collector,
CMHO and nodal officers of National Blindness Control Programme are
demanded with immediate effect. In the course of events, one can see the
tendency of putting all blame on a single doctor, whereas all concerned State
and District health and administrative officials should be investigated and
due criminal action taken.
6. At least one member of each affected household should be provided means
of regular livelihood. Free Medical facilities should be provided to all affected
families.
Investigation done by:

Rakesh Chandore, Dhara, Amulya Nidhi, S.R Azad - Jan Swasthya Abhiyan
Medha Patkar, Devisingh Tomar, Bhagirath Dhangar, Rahul Yadav - Narmada Bachao
Andolan
Contact : 9425311547, 9818111755
Posted by Thavam