The Telegraph
Since 1st March, 1999
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Inquiries that hide, rather than reveal

Governments revel in inquiries. Give them a pretext and they would constitute a committee. Provide them half an opportunity, and they would happily form another committee to monitor the findings of the first. They would generally be known to everybody. But the inquiry report, through a convoluted process, would let people know what ideally should have happened; and since conditions are rarely ‘ideal’, why it would be foolish to expect it in the first place.

This familiar pattern is being re-enacted all over again by the health department, which last week constituted another ‘expert panel’ to vet the findings of a team constituted earlier to inquire into the unfortunate death of a 17-year-old, who had merely broken a shin bone during a cricket match.

A broken bone in the lower limb can rarely be fatal. It was, therefore, an ‘open-and-shut’ case from the beginning, indicating ‘collective irresponsibility’ of the doctors, paramedics and other staff that nipped a cricketing career in the bud. If such a case had taken place elsewhere, the hospital superintendent would have had the authority to fix responsibility and recommend suspension or other forms of suitable punishment. But the health department does not appear to have much confidence, rightly or wrongly, in the superintendents.

The official inquiry could have taken the form of an ‘administrative inquiry’ to fix responsibility. It could also be a ‘medical inquiry’ to ascertain the cause of death and whether the course of treatment was correct. Finally, it could address wider issues and find out the ‘systemic failures’ that require correction. But the focus of the official inquiry remains uncertain.

It would be enlightening, for example, to find out whether the teenager was the first or the only patient to have died in the orthopaedic ward of SSKM Hospital. The number of unsuccessful surgical operations and the rate of infection in the ward would be other indicators to show if all’s right with the hospital. Information such as these should, perhaps, be displayed prominently to inspire confidence in the people, ensure transparency that would inevitably exert pressure on medical teams.

But neither doctors nor officials appear to be motivated by any such desire to improve hospital administration. That is why the secretary of the Indian Medical Association was quoted as asking if it was fair to suspend the orthopaedic surgeon on the basis of a ‘one-page inquiry report’. Would a ‘four-page’ report make a difference'

Even the health department, which perforce suspended the surgeon, has been taking pains to explain that the doctor was not present during any of the five operations that the victim went through in the hospital, though he, as head of the medical team, was responsible for the treatment. The surgeon himself has been quick to point out that there were nine members in the medical team and, therefore, it is unfair to single him out. Thus, even before the official inquiry is completed, the outcome appears to be a foregone conclusion.

Expertise of the World Health Organisation is surely not needed to improve internal communication, monitoring, quality of supervision and proper maintenance of medical records and bed-head tickets. Nor does it require any genius to conclude that both the surgeon superintendent and the head of the department of orthopaedics should also be held accountable for their failure to monitor complicated cases.

The city, which once boasted of doctors with almost miraculous healing powers, is fast acquiring notoriety for callous medicare. Therefore, dealing with one case at a time, and then waiting for the next crisis, is the kind of ad-hocism that simply will not work.

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