An official investigation into the death of a patient from Kollam has uncovered a chain of serious failures and negligence across multiple government healthcare facilities in Kerala. The expert committee, appointed by the Director of Medical Education, found that critical delays in diagnosis and treatment at three separate hospitals ultimately led to the tragic outcome.
A Cascade of Failures Across Hospitals
The committee's report paints a grim picture of systemic breakdown. It all began at the Chavara Community Health Centre (CHC), where there was a significant two-hour delay in arranging a crucial CT scan and an ambulance for the patient, Venu. Despite a doctor's referral to the Kollam District Hospital, authorities there refused admission, wrongly citing a lack of facilities. Shockingly, the case sheet recorded the referral as being made at the patient's insistence, not the doctor's.
The situation did not improve at the Kollam District Hospital. The report states that Venu's condition was not diagnosed promptly, and immediate emergency intervention could have saved his life. A major contributing factor was the non-functional 24/7 catheterization laboratory (cath lab), caused by a severe shortage of interventional cardiologists and supporting staff. The committee concluded that immediate thrombolysis or a Primary Coronary Intervention (PCI) at this stage could have been lifesaving.
Critical Delays at the Medical College Hospital
After further delays in referral and transfer, Venu finally reached the Thiruvananthapuram Medical College Hospital (MCH). Here, the committee found more grave errors. Despite being critically ill, he was admitted to a general ward instead of the Intensive Care Unit (ICU), which delayed essential critical care.
Although a cardiology consultation occurred in the emergency department, there was an unexplained delay in starting medical treatment once he was in the ward. The report also notes that the option of angioplasty was discussed with his relatives but was not formally documented in his medical file. Adding to the distress, hospital staff reportedly did not assist his wife, Sindhu, as she struggled to transport him in a wheelchair.
The Final Outcome and Committee's Stance
Venu was admitted to MCH after the crucial "window period" for primary angioplasty had passed. From November 2 to 5, doctors reviewed his condition, but an angiogram was not performed. His condition deteriorated, and on the evening of November 7, he developed cardiac distress at 7:15 PM and suffered a fatal cardiac arrest at 10:45 PM.
Despite identifying clear and serious lapses at the Chavara CHC, Kollam District Hospital, and Thiruvananthapuram MCH, the expert committee's report does not recommend any punitive action against the hospital staff involved. Instead, it advises improving communication with patients' relatives and implies systemic fixes are needed. The report underscores that the collective failures across the healthcare chain robbed Venu of a fighting chance at survival.
