Five persons were killed in this fire presumed to be caused by the humidifier of Dhaman ventilator, manufactured by Rajkot-based Jyoti CNC.

Severely criticising the Gujarat government’s policy on outsourcing jobs of fire personnel as well as negligence of hospital administration, two reports of the (retired) Justice DA Mehta Commission of Inquiry looking into two incidents of fire that killed 13 Covid patients last year, recorded that the fire in Rajkot hospital started from Dhaman ventilator provided by a private firm to the state government.

Recommending that privatisation be restricted only to commercial sectors and “not where public health, life and safety of citizens was concerned”, the reports, on the incidents at Shrey Hospital in Ahmedabad and Uday Shivan-and Hospital in Rajkot, submitted to the then chief minister Vijay Rupani in March, were tabled in the Assembly on Tuesday.

Based on affidavits submitted by electrical inspector at Rajkot, Manojkumar Hansaliya, FSL officials and Directorate of Forensic Science in Gandhinagar, and the only eyewitness, nursing staff Maheshbhai Kunvariya, the Commission observed, “…The first spark occurred in thermo sensor located in hard flexible transparent pipe attached to the face mask…. of the patient in bed number 103, resulting in the pipe carrying oxygen to the patent catching flash fire… the patient’s hair caught fire… There was a second blast in the machine resulting in spreading of fire.”

Five persons were killed in this fire presumed to be caused by the humidifier of Dhaman ventilator, manufactured by Rajkot-based Jyoti CNC.

In the case of Shrey fire, the Commission took into account the FSL findings, which suspects that the fire could have started due to sparking (short circuit) in a patient monitor that was reportedly 15 years old, three times its prescribed life span.

Noting such lapses, the Commission noted that there is no policy to change or replace ventilators and other critical medical equipment which use electrical power and that a database should be maintained and simultaneously linked with the annual fire NOC certificate application. The state has admitted that “it is a policy issue” and that the government “will examine it further”.

In Shrey incident, the Commission said, Bharat Vijaydasji Mahant, who along with his family has 86% stake in the hospital, “has to be held guilty of negligence”, saying he was “solely responsible for the incident” of fire.

Noting that the policy of hiring personnel by mode of outsourcing “is not only detrimental” but also creates a “culture which yields negative result by way of outright poor performance”, the Commission questioned the quality of service when the lowest bidding contractor is awarded the work.

Mincing no words, the commission said fire emergency services is an essential service, and that it “cannot be dependent upon or supplemented by persons who have been outsourced through a contractor” and added that “the state government has to realise that it is required to govern… and not make a show of governing”.

The Commission also recommended that the “concept of privatisation has to be restricted and made applicable to only in sectors, which may properly be described as commercial” and not where public health, life and safety of citizens are concerned.

The state government, in its ‘action taken’ measures, clarified that the policy of outsourcing was a “temporary arrangement”. However, the government refused to accept the Commission’s recommendation on revamping the fire brigade system, saying fire service is part of 12th schedule of the 74th Constitutional amendment and state will only monitor the services while effective implementation-related measures will be left to the discretion of urban local bodies.

Coming down heavily on government practice of regularising unregularised construction by paying a fee, the Commission noted that “there cannot be (such) a blanket policy”, and clinical as well as educational premises, especially, should not be permitted to operate in illegally constructed premises regularised by paying such fee.

It noted that if unauthorised constructions on the premises of Shrey Hospital were not regularised, the incident on the night of 5-6 August, 2020, could have been avoided.

Noting that many small hospitals function in commercial buildings not meant for a health setting, the Commission recommended that there has to be structural changes and revamping of electrical load. The state, however, accepted this recommendation only partially, clarifying that it will ensure fire NOC for all hospitals that can be provided without making structural changes.

The Commission has also recommended two staircases for emergency exits — a measure that was absent at Shrey Hospital, to which the state said it shall be implemented in new hospitals.

Noting that there is no statutory provision which governs the registration of nursing homes and hospitals, it recommended that the Gujarat Clinical Establishments (Registration and Regulation) Act be implemented.

Rebuking the practice of payment of ex gratia to the kin of the deceased by the state, the commission questioned “why a taxpayer should bear the burden of misdeed or laxity of the management of the nursing home”, and said it must be borne by the management of the nursing homes.

The Commission also found out that hospital staffers in the two hospitals were not well-trained to tackle an emergency and suggested that the state formulate a policy. It also noted that temporary obstructions and bifurcations set up to demarcate areas treating Covid patients from other areas in hospitals was a “problem area”, when it comes to fire safety. The Commission recommended that hospitals should remove such obstructions, including false ceilings, glass facades etc.

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