Human error ‘kills’ patient at Sion hospital

Miss Alone

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MUMBAI: A first-year resident doctor at Sion Hospital, suffering from a panic attack, ran away from a busy ward last Tuesday, unleashing a chain of events that ended in the death of a patient.

A senior citizen from Bhandup, caught in the bizarre turn of events, died with 15 minutes of a minor procedure to drain fluid from his lungs carried out by the replacement doctor.

The family of Waman Zare, 65, alleged that the procedure was carried out in haste, without their consent or supervision of a senior doctor. An informal internal investigation has revealed that the doctor had punctured the left lung instead of the affected right, sending the patient into a cardiac shock.

Authorities at Sion Hospital confirmed the incident, but no inquiry has been ordered yet. Acting dean Dr N D Moulick said it was a case of "human error" and not something attributable to stress or work pressure. The ward with 84 patients was being manned by only two resident doctors.

Zare had been hospitalized and treated for fever and stomach ailments at BMC's Veer Savarkar Hospital in Mulund before being referred to Sion Hospital on August 4. An X-ray at the Mulund hospital had shown accumulation of water in the lungs. On August 4, Zare took discharge and headed to Sion Hospital for draining the fluid.

"We had lunch together in Mulund and walked till the bus stop to catch a bus for Sion Hospital. We discussed how water removal from lung was a minor procedure and he would be home in a day or two," said his son Rahul, 30. "Little did we know that he would be dead by that evening," he said. Zare got admitted around 4pm and passed away in a span of little over two hours. He is survived by his 65-year-old wife and four sons.

The family claimed that the woman resident doctor attempted the fluid draining procedure without studying his file properly. "There were no seniors around. It was visible that something was wrong. My father immediately started complaining of breathing difficulty. He was shifted to his bed soon after and put on oxygen support. He died within 15 minutes," said Rahul. He added that the cause of death was not explained to them. The death certificate issued to them says Zare died of "cardiac shock".

TOI has learned that the hospital had insisted on a post-mortem, but the family refused. "We knew our father will never come back. So what is the point of getting into procedural hassles?" he said. The family's consent should have been sought and the dangers of the procedure duly explained to them, he added.

Moulick said not seeking a patient's consent was a major oversight. "These are certain procedural things which our residents have to be trained better in. Such incidents are rare though," she said.

The woman resident doctor had come to help after the other doctor fled the ward following a panic attack. The doctor, who had been suffering anxiety attacks, had not informed his department about his health condition. He is currently taking treatment and is on leave, added Moulick.

"Handling nearly 100 patients in a single ward and dealing with their relatives is not easy. Often senior doctors are not around to teach us how to deal with such situations," said a resident doctor from the hospital.

About 10 days ago, a resident doctor from KEM Hospital had attempted suicide when he failed to cope with the work pressure. The Maharashtra Association of Resident Doctors (MARD) has been demanding that their work duties be restricted to 48 hours per week.
 
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