Prisoner’s death: PHC report contradicts CMIT findings

LAHORE: Punjab Healthcare Commission’s inquiry to fix responsibility over negligence in the death of an under-trial female prisoner at Kot Lakhpat Jail due to cardiac ailment has gone off-track as it prima facie tended to save the responsible from Punjab Institute of Cardiology – earlier charged with negligence by a high-powered committee constituted under Chief Minister’s Inspection team. The PHC, in its decision dated March 7, 2017, held medical staff of Kot Lakhpat Jail, including a woman medical officer, earlier praised in the report of CMIT’s inquiry committee, completely responsible for the death of under-trial female prisoner after failing to fix responsibility for medical negligence committed at the PIC despite referral by the jail’s medical staff twice, which led to patient’s death due to acute myocardial infarction.

Following the order of Punjab Chief Minister Mian Shahbaz Sharif to hold an inquiry into the death of female prisoner Ulfat Bibi alias Baybi, w/o Muhammad Iqbal, a resident of Faisalabad, on November 8, 2014, CMIT’s inquiry committee comprising Kokab Nadeem Warraich, Member General-V, CMIT, as convener and Prof Dr Faisal Masood, the then vice-chancellor of King Edward Medical University, as member conducted a detail inquiry on November 12, 2014 and came to the conclusion that the patient died of acute myocardial infarction with or without arrhythmia and left heart failure.

It held WMO Jail Dr Nusrat Naz, in-charge of the morning clinic, responsible for not recording the patient’s vital information and past history of hypertension, diabetes mellitus and ischemic heart disease and, as a result, her treatment in jail (though appropriate) remained symptomatic and of emergency nature and making a routine request instead of an emergency call to PIC.

On the other hand, it said, the on-call Emergency WMO Jail, Dr Tooba Ashraf, did a good job of diagnosing the condition correctly as a heart ailment and started all the appropriate medical on both her visits in addition to the emergency referrals to PIC. On the third occasion, Dr Tooba, upon finding the patient BP-less and pulse-less, referred her to Jinnah Hospital for expert management but, unfortunately, she died on the way. With regard to negligence on part of the PIC, the committee noted that, in the context of repeated attacks and suggestive history, the patient’s condition warranted an evaluation by a senior person before discharging from the hospital.

Based on these findings, the committee recommended proceedings under PEEDA Act/relevant laws be initiated against WMO Kot Lakhpat Jail Dr Nusrat Naz for her act of negligence and inefficiency and she be immediately replaced by a competent WMO. It further recommended that the decisions taken, regarding the management of Ulfat Bibi at PIC, may be referred to Punjab Healthcare Commission with cardiologists on board to fix and apportion the responsibility as to why the patient was discharged twice without realising severity of her ailment in the context of her suggestive history.

The CMIT chairman also gave his comment saying, “As per inquiry conducted under Mr. Jiwan Khan, the deficiencies of PIC emergency were identified and included lack of consultant supervision and back-up.” Thhe Board of Commissioners decided, “The healthcare establishment i.e. Punjab Institute of Cardiology is exonerated from the charges of medical negligence. However, the Board of Management of PIC is directed to develop and implement the SOPs for recognition, registration and management of medico-legal patients."