From: Medical Negligence Standing Committee Date: 23 February 2023 To: Senior Chief Executive ‘Ministry of Health and Wellness Medical Negligence Standing Committee (Enquiry into the Death of Dialysis Patients at New Souillae Hospital) 1, By eter Ref No: MHC/DHISH dated 14 November 2022, the Ministry acinowledged having taken “cognizance of the preliminary Report ofthe MNSC on the above subject” and “would wish to be appraised of detils regarding duties and responsibilities of officers on matters which ought to have carted out forthe care ofthe patients” 2 By emai of 16 November 2022 requests were made for specific records anddocuments and alist in chronological order of personnel employed at Tamassa, ENT, NSH between 25, March 2021 and 14 April 2021, Unfortunatly, those requests were lft without reply 3. The Committe is now submiting ts final report on each of the I eases whein after Tengthy review and consideration, the gist and substance contained in the abovementioned preliminary report are predominantly unchanged, 4, However, wherever possible and relevant, further details and clarifications ere brought to the conclusion as requested; of course the Committee has home in mind the serious constraints and working environment tat prevailed atthe material time ML. Nuckchady Chairperson ‘Medical Negligence Standing Committee Ye Ahuchetn hy PRecanat. fom Se AA on bt Mak 2023 A Ufiy Mon a aay rs eh hotel rer LCE. ollIntroductory Notes 025 March 2021, the Ministy of Health and Wellness was informed tat sverl patents | undergoing dialysis at New Souilac Hospital (NSH) were in contact with & member of the | personnel who was found tobe positive to COVID 19. In order to curb and prevent any possible outbreak inthe community, and as most of those patients were from areas in the vicinity of NSH, a decision was taken on 26 March 2021 to send those contacts for quarantine at Tamassa Hotel which was then a declared Quarantine Contre Eleven (11) of those dialysis patients passed away during the petiod 29 March to 19 April 2021. Infabout April 2022, the Medical Negligence Standing Committee was requested by the Ministry of Health and Wellness to cary out a preliminary inguiry inthe treatment and ‘management ofthe late eleven (1) patients while they were in quarantine an or atthe NSH. ‘while in isolation and undergoing dialysis treatment. ‘The Committee had therefore to cary out lengthy and in depth interviews with all relevant Parties including the Medical / Nursing personnel in order to ascertain any evidence of negligence as per the brief. Furthermore, invitations fr interviews were sen 1o all relatives / interested rarties who had first-hand knowledge or been in touch with the deceased atthe material time, Except for late patients Bissoo and Soobraty, the related partis of the other 9 deceased responded positively tothe MNSC invitation, ‘Those who attended the Committee provided invaluable information and raised disturbing issues regarding the Tamasse Quarantine Centre, especially the poor and more often the lack of medical/nursing care and attention. They were all unhappy with the manner in which transport was organized to convey the patients initially to Tamassa Centre aed thereafter to NSH. The complains from the relatives also focussed on the standard of catering in general at porRegardless late Mr Bissoo who was a vulnerable patent with past history of seizures and on poychotropic drugs fully required constant care and attention, and should sever have been kept isolated, unattended and unassisted, 8. I is an undeniable fact thatthe overall administrative management regarding the Dialysis patients was fr from perfect and lacked meaningful empathy. 2) There was a lack of preparedness by the tum of events resulting in poor staffing and lack of appropriate logistics especially fr those dialysis patients in quarantine. b) The administration ought to have been aware and sensitive to the special needs of patients with Renal failure on Dialysis, The Dialysis patients though vulnerable, were considered just as any other “contact tracing residents”. ©) Tt. was when the patients and their relatives voiced out thelr grievances in the press ‘and on the social media that some corrective measures in tems of the quality of meals, cconveyance and transport, psychological suppor, medical assistance and stafing needs were taken, eas unfortunate that several ofthe Nursing Officers posted atthe Tamassa Cente were contaminated and needed to be isolated This led to an acute shortage which impacted ‘negatively onthe standard of medical and nursing care. Dr Oozeerally viewed that “logistics ‘na crisis situation is not the same as in @ normal situation” Conelus 8) Late Mr Dharmanand Bissoo had not reesived the expected standard of care and treatment while in quarantine. This may be as a result of the stalling situation then prevailing and as well asthe complete lck of supervision by those concerned, b) The contributing factor leading tothe patent's death was probably the physical and psychological stress he had to endure during the multiple trensfers and white he-was Kept isolated in room without adequate medical care and family support. ©) In the absence of relevant documentary evidence, relying mostly onthe information ‘blained durin interviews, and taking in consideration ofthe serious conser in which the staff were roquited to work, part of the atending personnel Regardless the decision to isolate such vulnerable patient in the above described conditions 4 a® Page 5 0f 64) The committee concludes thatthe Ministry may be minded to refer tothe appropriate authorities the Offices's who took the decision fo quarantine Dialysis patints at Tamassa Centre, including lte patient Bissoo, without having ensured the provision of adequate staff to caer forthe special needs of such vulnerable patients and for failure to have provided the ‘asic medical care and atlenton It is also on record that Dr Deepchand, RPHS did repeatedly ‘mention that the decision wns taken “dep a hau” ‘The committe is unable to specify the name of the officers concerned piven that its request, to the Ministry forthe communication of relevant names has lad no response, a dB CRS [Rae | ER as] ese [SRS ; a Geo De Goowdoyal | Member | 33 Feb 2025 Ge MD. Bhujobary | Secretary 3 Feb 2023 | Ye : Page 6 of 6hog $ Enquiry No 3: Case of late Mr Mahadoo JEEBUN ‘The Ministry of Health and Wellness has requested for an enquiry into the cases of Eleven (11) deceased patients who were on regular Haemodialysis at Soullac Hespital and who, following exposure to Covid-19 eases, were quarantined at Tamassa Hotel. Mr Mahedoo Jeebun was one of them, Late Mr Jeebun was quarantined at Tamassa Quarantine Centre on 26 March 2021. He was tested positive forCovid-19 on 2 April 2021 and transfered to Isolation Ward, Soullae Hospital. He passed away on 11 April 2021 with “SARS-COV? associated with DMHBPICKD", ‘Complaints: Mrs Nishila Hanzary and Mr Keswar J Hanzary, respectively the daughter ard son-in-law of late patent Mahadoo Jeebun were heard at an interview held on 01 June 2022.The following isanexnet of their complaints 8) 0126 March 2021 at around Noon, the patient was requested by phene to get ready for transfer to Tamassa Quarantine Centre. It is only at 18 00 hours that « 15 seater van picked him up fiom his residence at Surinam, ‘On the way, the patent had been shifted into a bus with other Dialysis patiens. The bus was still at Riviere des Gallet at 22.30 hrs and finally reached Tamassa Centre at 23.45 hrs ‘The patient had been in transit for nearly 6 hous in very uncomfortable conditions and had ‘missed his dinner. He was made to wal up tothe 2 loge and had to cary his bag himself to his room. He got nto his room a around 00.15 hrs, hngry, exhausted and ansous ¥) On the night of admission, patient was served “Briyani” which he could not eat. The meals served on the following days were unpalatable and was not appropriae for him as a Patient with Renal Failure. ©) While at Tamassa, the patient was Kept isolated ina room and did not receive any visit from either a Medical or a Nursing Officer. He had to clean his room himself though he as not well. He was psychologically disturbed and depressive, 8) The Dialysis sessions were not caried out as scheduled (missed a session on 27 March) and the duration was also shortened on certin day, ©) _0n29 March 2021, patient was breathless after the Dialysis session which was carried ‘out in the afternoon, When he was brought hack to Tamassa, he had to climb up the sais to bis room. 1) The relatives were not informed by any heath Authority when the patient was tested positive for Covid-19 on 2 April 2021. Nor were they informed when the patient was rants Len Gas i >transfered to Souilac Hospital. There was a complete lack of communication from the Ministry of Health staf. 8) At Soule Hospital, no specific treatment was given for Covid and no doctor was tending to the patient. Even the Nursing Officers were not providing any assistance. The drugs prescribed for the day were kept ina plastic bag atthe bedside. The food served was, inappropriate, 1h) Patient was not given Oxygen as had been advised by the Medical Oticer on 6 April 2021, despite patient being breathless. On 7 April, patient was not well and in distress. He informed his wife by phone that he was not being attended to or given the nevessary care. He Ina asked his wife to seek help 8) O18 April 2021, consent for putting patent on Ventilator was sougt from relatives at 14.15 brs when in fact patent had already been on ventilator since the morring, i) No offer was made fo relatives to stay with the patient at Tamassa Centre. After the demise of patient, when relatives went fo collect his belongings ftom Souls: hospital, they noticed that patient's watch, mobile Phone and purse were missing. They had reported the ‘matter to the Medical Superintendent. They have not been able to recuperate these items and they believe that these have been stolen Atinterview, the complainants handed over a complaint letter to this Commie, The letter is annexed to this por, Summary of ease: Late patient Jeebun Mahacoo, 57 years old (DOB 01/10/1963) was a known eae of Diabetes Mellitus, Hypertension and Chronic Kidney Disease, He was initiated on Hsemodialsis in December 2013 and hed since been on regular thrice weekly haemodialysis at Soul Hospital HDU, On 26 March 2021, several HDU staffs were tested positive for Covid-19 and as in accordance to the prevailing quarantine regulations, late Me Jeebun had to be quarantined and assent to the Tamassa Cente, (On 26 March 2021 (Day 0), Mr Jeebun was tested negative for Covid-I9(CR -ve). No record is available onthe health status of the patient while he was quarantined at Tamassa Cente from 26 March to 2 April 2021 (On 2 Aprit 2021 (Day 7), Mr Jebun was tested positive for Covid -19 and was transferred to Souillac Hospital where he was admitted othe isolation ward. From 2" to 6" April 2021, Me Jeebun was asymptomatic and general condition was stable with normal vital parameters, He ‘was followed up and assessed daly by Dr Dessi, MHO, under the supervision of Dr Oozeeraly, nephrologis. All necessary investigations were cartied out aecordiagy. mores 6 BATH tpOn 7 April 2021, at 7.30 hus, patent developed shortness of breath and fever. He was attended by Dr Desai and Dr Ancharaz, Nephrologist. Patient was pyrexia (T 38.7°C), Hypoxic with Spo2 of 82% on air and had bilateral crepitations on auscultation. Patient was shifted to the “Critical Ward” and appropriate medication preseribed (Rocephine, Dexamethasone, Lovenox, Perfalgan, Oxygen). Needful investigations including an urgent (CT Scan of Thorax were requested. During the day of 07.04.2021, the patient had & CT Scan of Thorax done at ENT Hospital and it showed extensive diffuse ground glass opacities in both lung fields with a Covid severity score of 1825, ‘When the patient came back from ENT Hospital at 16.00 hs, he was stended by Dr Ruchichan, Anaesthesiologist. In view of the CT Sean findings and the clinical condition of the patent whose Oxygen Seturation was dropping (84%), Dr Ruchchan advised connecting him tothe CPAP apparatus. Unfortunately, the patient could not tolerate the CPAP and he ‘was reverted back to Venturi Mask” at 21.00 hrs. The next moming of 8 April 2021 at 10.20 hrs, the patient was found to be in respiratory distress (Tachypnoeie, Spo? 70-75%) and the blood gas Analysis indicated « metabolic acidosis (pH1 7.21 and Pa02 46mm despite Venturi 02)._Dr Ruchehan tok the decision to inubate the patient for controlled mechanical ventilation. He was also put on inotropic support as he was haemedynamically unstable and the medications were reviewed, Patient was followed up closely by the team of Nephrologists (Dr Dessi and Dr Anchataz) and Ansesthesilogist (Dr Ruchchan and Dr Gooljaz). On 9 April 2021 his condition kept deteriorating and had an episode of pulseless Ventricular Fibillation at 17°30 hrs but was suoeessflly resuscitated after DC Shock. He underwent haemodialysis after stabilization, (On 10 April 2021, patient was sill in extical condition despite intensive therapy and on 11 April 2021 he went into Ventricular Fibrillation at 12.30 brs followed by asysole, Despite all resuscitative measures patient passed away a 13.00 rs, ‘The cause of death was cetified as being due to “SARS-COV? infection associated with ‘chronic kidney disease” with Diabetes and Hypertension as co-morbidiis. ‘Methodology The following documents were sertnized 1. Patents case file from J, Nehru Hospitals 2. Tamassa Quarantine Centre Occurence Book; 3. Extract from the Occurence Book of Souillac Renal Dialysis Unit; 4. List of Medical and Nursing Staff posted at Tamassa Quarantine Cente; and 5, List of Medical and Nursing Staff posted at the Soullae Dialysis Unit a.The following relatives were interviewed: 1. Mr KeswarJaidev Hanzary; and 2. Mrs Nishita Jeebun Hanzary. ‘The following stalls were interviewed forall 11 cases including the present case 4. DrDeepehand, Regional Public Health Superintendent 2. Dr Karamjeet Sewchurm, Dr Nasi! Doomun and Dr Irvin Dookun, Medieal Officers posted at Tamassa Centre. Mr Ramgoolam, Nursing Officer in Charge at Tamassa Centre Mr Dev Rishi Bajah and Mrs Nalini Lutchmun, Nursing Officer, Tamassa Cente Mr Sachin Caunye and Mr Saad Sekunder, Dialysis Nursing Officer, in isolation at Tamassa Cente, 6. Dr Ruchpaul, Medical Officer posted at Souillac Dialysis Unit. 7. Mas lakkoomee Callingee, Nutsing Officer, Dialysis Unit 8, MrMotamad Reza Raheeman, Nursing Officer Dialysis Unit 8. Mr Jugroo, National Dialysis Coordinator 410. DrPreetum Anchataz, Nephrologis. 11. DrChiniah, Medical Superintendent, Souillac Hospital 12, Dr Oozecrally, Nephrolgis. This isis not exhaustive, A fil isi annexed to the introductory remarks, Observations: 1, The complaint of the relatives concerning the undue delay inthe conveyance ofthe patent fom his residence to Tamassa Centre on 26 March 2021 are justified, The patent was informed that he will be picked up for transfer to Tamassa Centre at 11.00 hrs, was picked up around 1800 lus an reached Tamassa at 23,30 brs 2. There are no clinical notes availabe to this Committee on the clinical health status of late Mr Jeebun during his stay at Tamassa Quarantine Centre, from 26 March 2 April 2021 i appear that neither any monitoring had been earied nor were any vital taken, Mr-Jeebun was a Diabetic and the least expected would have been regular blood sugar test which was not caried out. Atte interview: 8) The Nursing Officers stated that despite the acute shortage in manpower, they had been carrying out regular rounds and taking the Vitals of Dialysis patients twice daily but Ln ye Page 4 of 6 fsb) The Medical Officers (Dr Doomun and Dr Sewehurn) stated that they had not recorded any oftheir clinical observations and findings, neither for patient Mr Jeebun, nor for any other quarantined patients. However, ffom information gathered through relatives of other deceased Dialysis patient, it appears thatthe Dialysis patents were left isolated in their rooms, without any assistance and ‘vith are visits from the medical staf. 3. Relying on the elinial notes in the ease fle and on the statements made by the attending MHOs and Specialists, it appears thatthe patient was clinically well managed at Souillac Hospital as from his date of admission on 2 April 2021 until his demise on 11 April 2021, He was assessed daily by the Medical Officers and appropriately investigated. When he developed symptoms of Covid infection, he was shiled to the Crtial Care ward and presribed the drugs according to the existing protocol, Despite all the resuscitative measures which were caried out as required end in time, the infective process progressed unabated, leading to respiratory failure ad multi-organ dysfunction 4. Before being quarantined, the patient had his last routine Dialysis on Thursday 25 ‘March 2021. Due to closing down of Soullac Hospital for disinfection and fumigation, he ‘had missed his session scheduled foe Saturday 27 March 2021 However, he was Dialysed the next day on Sunday 28 March 2021 (3 hous" duration as stated by Dr Oozcerally). Thereafter he had regular Dialysis sessions on 30 March, 2 3 6 and 9 April 2021. On 8 April 2021, he could not be dialysed because he was on Controlled Venilation and haemodynamically unstable, on inotrope. ‘5. As regards tothe Nursing care and monitoring ofthe patient at Soule hospital this ‘Commitee has no documentary evidence 1 ascertain whether those duties were caried out appropriately. thas been established that there was an acute shortage of Nursing Officers until the second ‘week of April, and as such, the standard of nursing care was not asin normal times. Hence, the complaint from the relatives that patient didnot receive the required standard of eare may be plausible 6 Inregaris tothe complaint that no specific treatment was given for Covid, itis worth ‘mentioning that during that period there was no specific antiviral drug for those aficted by the COVID-19 virus. Hence the main medical treatment was essenilly symptomatic and Lo Or BR_ Page § of 6 (yeConclusions: 1 It is an undeniable fact thatthe late patient Mr Jeebun was made to undergo certain uncomfortable moments, hardships and even distressing situations while being eonveyed to, and isolated at, Tamassa Cente 2. As a Dinbetic patient on Dialysis, he ought to have been quarantined in a set-up with ‘adequate provisions in terms of clinical monitoring, nursing car, dietary regulations and psychological support. Hence the complains regarding the late patient's difficulties at ‘Tamassa Centre were justified 3. The complete lack of communications at all levels on the part of thos responsible at ‘Tamassa and New Souillae Hospital has had distessful effects on the family of Mr. Jeebun and this was deplorable, 4. In the circumstances, the Ministry may be minded to refer to the relevart authorities the following: i. The Officers who took the decison to quarantine dialysis patients at Tamassa Cente ‘without ensuring the adequacy of staff and logistics and for failure to have considered lysis patients as extremely vulnerable people needing special medical care and attention. ii, The Dialysis Coordinator and the Transport Officer for ther respective fuilure to provide timely and safe transfer ofthe patient from his residence to Tamassa Cente. ‘The Regional Nursing Administrator (INH) and the Dialysis Coordinator for their failure to provide adequate stalling atthe NSH Isolation Ward and Dialysis Unit and for their failure to ensure meaningful supervision thereat. Te committe is unable to specify the name of the offices concerned given tha its request to the Ministry forthe communication of relevant names has had no response. Name Designation | Date Signature ML, Nuckehedy ‘Chairperson | 23 Feb 2023, AE Dr Boodhoo Member [2a Feb 2023? 7 DFS. Poonam Member] 3 eb 2005 DrR Goordoyal Member [25 Feb 2005 BP Mr. Bhujohanry | Seereary | 23 Feb 2025 Wize ; G Page 6 of 6Enquiry No 4: Case of late Mrs Avishna Parvatee JENA ‘The Ministry of Health and Wellness has requested for an enquiry into the eases of Eleven (11) deceased patients who were on regular Haemodialysis st Soullac Hospital and who, following exposure to Covid-19 cases, were quarantined at Tamassa Hotel in March 2021, Mrs Jena Avishna Parvatee was one of them. The patent passed away on 19 April 2021 ‘Summary ofthe case: ‘Mrs Jena Avishna Parvatee, 38 years, was admited to J. Nehru Hospital on 2.09.18 with W/O orthopnoes, mostly at night. She was a known case of complete heat black, fr which a dual chamber pacemaker was inserted in 2014, She was followed-up at cardiac and medical opp. On 23.12.2019 she was referred to the nepbrologist with renal impsinnent. Necessary investigations and treatment were instituted under the general care of Dr Oozeerlly, Nephrologist She needed admission on several occasions up to March 202, fr anasarea die 1 Mud overload because of Chronic Renal Failure (CRF) and Congestive Cardiae Failure She started undergoing hemodialysis as from 03.03.2021 as she was not keen before that Cardiac Echo done on 06.01.21 revealed a hypokinetc anterior wall, EF=5( %, concentric Jeft ventricular hypertrophy and minimal pericardial effusion, ‘The patient was quarantined at Tamassa Cente as from 26.03.2021. The PCR test done for Covid-19 (Day-0) was negative. On 02.04.2021 being found postive for Covid 19 she was transfered from Tamassa Hotel t the Isolation Ward of New Souillae Hosgital (NSH) (on Day 7 PCR test), On 05.08.2021, while she was undergoing dialysis at NSH RDU, she vomited once and became uneasy with suspected episode of seizure, with BP~ 230/100 mmHg, HR= 159/min, ‘and Sp02+75% and the patient collapsed. She was attended by De Oozeeraly, nephrologist, and the anaesthetist. After elnical stabilization, she was transferred back tothe isolation ward, ‘There isan entry in the patient’ case file that she was sent to ENT and back on 06.04.2021 but no further details available on the reason forthe transfer, She was more of less stable up to 16.04.2021, when she had cofee-grown vomiting and necessary tretment given for stress ler On 19.04.2021, at 15.30 hrs, the patent became agitated and uncooperaive, rising a suspicion of Cerebrovascular Accident. request for CT Scan Brain was made and she had (o be conveyed to ENT for same by the SAMU team, Unfortunately, there was a delay for ‘conveying the patient to ENT as the SAMU was taken up witha polytrauma zase. At 19.45, hhout, the patient suddenly collapsed with cardiac ares. Resuscitation was unsuccessful and the patient was declared dead at 20.15 hours. The cause of death was recorded as: Cerebro ‘Vaseular Accident, End Stage Renal Failure on dialysis, SARS-Cov 2 positive, gq Biv LapMethodology: ‘The following documents were scrutinized: |.Oscurence Books of RDU & Isolation ward (NSHD, and Tamassa Hotel 2.atients case file from J. Nehru Hospital and Isolation Ward, New Soulla Hospital; and 5 Lists of medical and nursing staff posted at Tamassa Hotel Quarantine Cette and Dialysis Unit, New Souilse Hospital ‘The spouse of the deceased patient was not available fr interview, ashe is abroad. Instead, the patient’s two cousins, Mrs Shalince Jumun-Narain and Mr Kiesaw Kumar Jum, me for interview, but most of their statements were information relayed to then by the patient and by third parties The following tas were interviewed for all 11 referred cases and including the present cas: 41. DeDeepchand, Regional Public Health Superintendent 2. DrSok Appadoo 3. Dr Karamjeet Sewchurn, Dr Naail Doomun and Dr Irvin Dookun, Medical Officers posted at Tamassa Centre. 4, MrRamgoolam, Nursing Officer in Charge at Tamassa Centre, 5. MrDev Rishi Bajah and Mrs Nalini Lutchmun, Nursing Offers, Tamassa Cente 6. Mr Sachin Caunye and Mr Saad Sekunder Dialysis Nursing Officers in isolation at Tamassa Cente 7. Dr Ruchpaul, Medical Oficr posted at Souilla Dialysis Unit 8. Mrslakkoomee Callingee, Nursing Officer, Dialysis Unit 9, Mr Mohamad Reza Raheeman, Nursing Officer Dialysis Unit 40. Mrs Nisha Chureetur, Nutritionist 11. MrJugroo, National Dialysis Coordinator 412. Dr Preetum Ancharaz, Nephrologis. 18. DrChiniah, Medical Superintendent, Souilae Hospital 14, DrOozeeraily,nepheologis. 16, DrNilesh Soowamber, RRT Doctor. ‘This ist isnot exhaustive. A fll list is annexed tothe introductory remarks Observations: 1. The patient was a known case of diabetes, hypertension, witha pacemaker, She was also suffering from Chronic Renal Failure and was on regular dialsis thrice weekly 2. At interview, the relatives stated the following: ‘the duration of dialysis sessions was shortened after patient was quarantined. ‘patient was on Insulin injection, but they were not aware whether she actually received it during her stay. ‘© delay in wansfer to Tamassa Centre at about midnight, after having waitsd in a bus for bout 3 our + no vite by mac or using stato examiner ding ber stay wTamase Conve. f{, renee @ en QBSunsatisfactory conditions of stay and fod served. ‘© poor communication with the family, both from Tamassa Centre and fron New Souillac Hospital, in the sense that staff were not reachable for several days, at times being rude, and no proper information about the patients condition and progress «allegedly, the first contact of the family with the staff of Tamassa Cente was after one week when she became positive to Covid-19 on 02.08.21, following which she was ‘transfered to New Souillac Hospital ‘poor nursing care at New Souilla Hospital 3. This Committee has no direct first-hand information on the hardship endkred by late Mrs AP. Jena at Tamassa Centre, as from the 26 March 2021 while she was iso ated in a room, ‘away from family support and without any assistance, ‘Thete are no available cinial notes (or records) upon which the committee can rely to fully investigate the management of late Mrs A.P. Jeon during her stay at Tamasse Quarantine Cente, from 26 Match to 02 April 2021, AL interview the nursing officers posted atthe Tamassa Cente stated that despite ofthe acute shortage of manpower, they had been carying out regular rounds and wking vials of Dialysis patients tice daily. They mentioned that they had not recorded same anywhere, The ‘Medical Officers (Dr Doomun, Dr Sewchum and Dr Dookhun) who were also posted at “Tamassa Centre confirmed thet they had not recorded any’ oftheir clinical observtions and findings, for any quarantined patients inching for Mre Avishna Parvatee JENA, However, ffom information gathered through relatives of other deceased Dialysis patients, it appears thatthe Dialysis patients were left isolated in their rooms, without any assistance and ‘with are visits from the medical stfT except for PCR tests and temperature checks This committee is more inclined to reckon thatthe patient had not bene‘tted from the required standard of clinical care and assistance at Tamassa Centre whle taking into consideration the inadequate staffing and facilites tht prevailed a the material time. ‘© The commitee took note of the problem of inadequate staffing, consistently by all stafT interviewed, hence the staff did whatever was humanly possible, © However, those deficiencies, as wel asthe decision to isolate such vulnerable patients ‘without any proper medical/nursing supervision is obviously unacceptable '* Although the dialysis patents generally deserved a more conducive and caring environment during quarantine and isolation, the committe fils to understand that, in view of the prevailing emergency and sanitary conditions, there was a lack of readiness and preparedness by those responsible at Tamassa Quarantine Centre and New Souillae Hospital specially during the second phase ofthe COVID-19 outbreak 4. As from the time the patient was transferred to Souillac Hospital on 02.04.2021 she was clinically well managed and attended by nephrologist daly. She had regular sessions of lysis as scheduled and was more or less stable til the 19.04.2021, albeit she remained positive to Covid-19 until she passed avay. CP masses D+ ‘om(On 19% march she was dialysed and transfused 2 Units of Packed Cells as she was suffering fom Gastro intestinal bleeding. On the same day, she suddenly had symptoms and signs suggesting a Cerebro Vascular Accident (CVA), ACT scan of brain was requested and she had to be conveyed to ENT hospital for same but ‘unfortunately this could not be carried out due to unavailability of SAMU at that time. While ‘waiting transfer, she suddenly collapsed inthe ward and passed away. Conclusions: Inspite of staffing and other constraints the patient was.clinically-well-managed at NEW Souile Hospital anther sme of ages Nevertheless, the Ministry may be minded to refer tothe relevant authorities the fllowing officers i. The Transport Offer and Dialysis Coordinator fr failure to provide basic comfort to patients including late Mrs Jena during their transfers from their respective residence to ‘Tamassa Centre, li, "The Regional Nursing Administator and Dialysis Coordinator for their failure to range for adequate staling atthe Tamassa Centre and atthe Suillac Dialysis Unit, ‘The Committe is unable to provide the name of the above officers being given that its ‘request forthe provision of relevant lst of names tothe Ministry have had no response, Tame Designation [Date [Sia ML, Nockchady —] Chairperson | 03 Now 2022 DFK. Boodhoo ‘Mambsr | 05 Now 2032 DFS. Poor Member [05 Nov 2033 DFR Goonoyal | Menber 05 Now 022 MD. Bhijohanry | Seeary [05 Now 2022 Page 4 of 4Enquiry No 5: Case of late Mr Luchoomaya LUTCHAMMAH. ‘The Ministry of Health and Wellness as requested an enguity into the cases of Eleven (11) deceased patents who were on regular Haemodialysis at New Souillac Hospital and who, following exposure to Covid-19 cases, were quaraatined at Tamassa Hote. ‘The Ministry of Health and Wellness has refered this case to the Medical Negligence Standing Commitee on 30.03.22 for a preliminary investigation. Mr L. Lutchammah is one ofthe 11 Dialysis patients who was quarantined following exposure to a Cevide19 positive ‘ase and who passed away’ while in isolation, Summary ofthe ease: Late Mr Luchoomaya Lutchammal, aged 72 years, was a known case of Diabetes Mellitus, ‘Hypertension and Ischaemic heart disease, having undergone Coronary Artery Bypass (CABG) grafting inthe past. He also suffered from Chronie Renal Failure for which he was on Dialysis therapy. (On 22.02.2019, he had been referred from Chamouny CHC to J. Nehra Hospital with features of Chronic Renal Failure (CRF). He underwent appropriate investigations and received {seatment with follow up at renal OPD under the care of Dr Oozeerally, Nephrologist. He had been admitted on several ovcasion with fluid overload and biochemical derangements, requiring hemodialysis which have been stated since 21.11.2019, Two months prior to his isolation, he had been diagnosed with Right Heat Failure with Ascites. His general condition was poor. He had lost weight, was jaundiced and had poor sobilty. On Friday 26.03.21 at about 11,00 am, the family of Mr Lutchammah was informed tht the all patents on Dialysis at New Souillac Hospital (NSH) had been exposed to Covid-19 through one of the staff who had ben tested positive for Covid. Therefor, he was requited to ‘be quarantined and had tobe conveyed to Tamasse quarantine Centre, “The family deplored the fact that the patent and his wife who had accompanied him, were picked up at 19 30 hours and made to wat in a 15.seater van, then a bus, before being conveyed to Tamassa Hotel at about 22.00 hrs. ‘At Tamassa Centre, Mr Lutchammah was tested positive for Covid-19 two days later, on 28.03.2021. He was transfered to Souillac Hospital in the middle of the mght at around 2330 hrs. He along with his wife and another patient, Mr Beodassy were admitted to isolation ward where they were the only occupiers. ‘On the next morning of 28.03.21, he was taken for Dialysis st 07.30 am, ror ARS sent ’His condition deteriorated in the night of 2903.21 when he became breathless and hypotensive. Barly on the next morning of 30.03.2021 at 06.00 am, he was transferred from New Souillac Hospital to ENT Hospital by the SAMU. He had guarded prognosis by virtue of the following clinical findings: Sp0::80% on 10 Limi 0:, BP:100/60 mmbg despite being on inotropic support. He had bata erepitations, pedal edema, mildly distended abdomen, jaundice +++, venticular ectoies and at ‘ibilation. His extremities were cold and clammy and his Glascow Coma Secre was 14/15 Mr Lutehammah was admitted to the ICU at ENT with a diagnosis of Septic Shock due to SARS COV-2 infection and cholangitis. He was attended by a physician and an snaesthesiologist ‘The next day (31.03.2021), Mr Lutchammah collapsed at 17.00 hrs just before a scheduled session to undergo haemofiltation. Cardiopulmonary resuscitation was in vain and he was declared dead at 17.30 hrs, The cause of death was writen as: Septicaemia, Chronic Renal Failure on dialysis, SARS-Cov 2 infection. Methodology: The following documents were sertinized: Occurrence Books of Tamassa Hotel Quarantine Centre, Dialysis Unit and Isolation Ward (NSH). 2.Patient's case file from J. Nehru & ENT Hospitals 3.List of medical and nursing staff posted at Tamassa Hotel 4.List of medical and nursing staff posted at Souillac Dialysis Unit The following relatives were interviewed: 1. Mrs Vinaygee Lutchammah, widow of late patient; and 2. MrKarunen Lutchammah, son of late patient. ‘The following stafls were interviewed fr all 11 referred eases including the present case 4. DrDeepchand, Repional Public Health Superintendent, mer poreDr Karamject Sewehurn, Dr Naail Doomun and Dr Irvin Dookun, Medical Officers posted at Tamassa Cente. ‘Mr Ramgoolam, Nursing Officer in Charge at Tamassa Centre, Mr Dev Rishi Baja and Mrs Nalini Lutchmun, Nursing Officers, Tamassa Centre, Mr Sachin Caunye and Mr Saad Sekunder, Dialysis Nursing Officer, in isolation at Tamassa Cente 7. Dr Ruchpaul, Medical Officer posted at Souilae Dialysis Unit. 8. Mes Ilakkoomee Calingee, Nursing Officer, Dialysis Unit 9. MrMohamad Reza Raheeman, Nursing Officer Dialysis Unit 410. Mrs Nisha Chureetur, Nutitonist, 411. MrJugroo, National Dialysis Coordinator 12. DrPreetum Ancharaz, Nophrologist. 48. DrChiniah, Medical Superintendent, Souillae Hospital 44. DrOozeeraly, nephrologist. 48. De Nilesh Soowamber, RRT Doctor. 16. Dr Awotar This list snot exhaustive. A fll ist is annexed to the introductory remarks. Observations: ‘The elinical notes in the ease file of patient and the entries in the Occurrence Books were scanty and lacking. The Committee had wo rely more on the information received at interviews ofthe staff and members ofthe family. Mrs Vinaygee and Karunen Lutchammah have provided important information onthe patient as from the time he was quarantined upto his demise 1. MeL. Lutchammah was on regular dialysis at Suillae Hospital, thrice weekly, since October 2019, He had several co-morbidities viz. Diabetes, Hypertension, Ischaemic Heart disease with Cardiae Failure and Ascites 2. He stated feeling unvell on Saturday 20.03.21 and on Monday 2203.21, he had developed a sore throat ‘The next moming (23.03.21), be attended Chemin Grenier AHC, where he was prescribed paracetamol tablets and gargle, but no test for covid-19 was carried out In the sime aftemoon he attended Souillac Hospital HDU for hs scheduled Dialysis session and he had informed the Dialysis Nurses about being unwell and suffering of sore throat. However, no due consideration was given bythe Nurses to his complaint. 3. On Thursday 25.03.21 he was taken by his son for Dialysis. Although he was sill having fever and was weak, no special attention or advice was given to him. His symptoms ‘were ignored by the staff and he was not even tested for Covide19 despite the outbreak of CCovid in Mauritius, The son stated that there was even a complete lack of basic sanitary precautions on the part of the Dialysis staff: They had not been wearing face mask watle attending to patients and hand santizes were not provided to patients. pad4, Later on the same day 25 March 2021, when patient was back home ater his Dialysis session, the relatives leant tata dialysis nurse at Soullac HU hha been tested positive for Covidel9, 5. On Friday 26.03.21 at about 11.00 am, Mr Lutchammsh was informed by a staff at Souiltae Hospital tht he had been exposed to Covid-19 and that he had to be quarantined at the Tamasea Hotel, ‘As the patient was dependent on his wife for his daily needs, including the change of diapers, the later had to literlly argue with the sanitary authorities before being allowed to accompany her husband 6. However they had to wait til 19.30 hrs before a 15-seater van picked them from home ‘They were then dropped at Chemin Grenier where they were made to board a bus which was already full. They then had to wait until 21.30 hours before the bus departed fiom Chemin Grenier to reach Tamassa Centre at around 22.00 hrs, Following admissior formalities by ‘ote staff, they were finally taken to their room at around 00.15 hrs (27.03.21 ‘Me Lutchammah was not seen by any medical or mursing staff during the wole night until around 7.00 am (on 27.03.21), when his temperature was recorded and swab for PCR test taken, Mrs. Lutchammeh stated that even the Nursing Officers at Tamassa Cente ad Jgnored her husband's complaints thet he was suffering from sore throat. No medication was prescribed 7.0m Sunday 28.03.21 t about 10.00 am they were informed thatthe patent was tested positive a Covid-19, and would be transferred to ENT Hospital. Mr Lutclammah was in Tact taken to ENT Hospital during the day but was again brought back to Tamasia Centre. Mrs, ‘Lutchammah stated that she was surprised to see her husband back so soon, According tothe staf, there had been a confusion in that Mrs Lutchammah was the person ‘who was PCR positive and not her husband, Consequently, instead of her huskind, she would be shifted to ENT Hospital 8, At imerview, Mr Karunen Lutchammah stated that he had to insist withthe Nursing Staff at Tamassa Centre for repeat confirmatory tests before the transfer of her mother to ENT Hospital. Repeat ests were carried out on both the patient and her wife at 14.00 fxs. The reports were made available at 22.0hrs and i confirmed that it was Mr Lutehammah himself ‘who was positive to Covid-19 and not his wife Mrs. Lutchammah complained thatthe patients legs were bleeding, presumably duc to injury sustained during his transfer to and back ftom ENT Hospital. She deplored lack of assistance Som the nursing staff, so that she had to apply a dressing on her own, 9.n the same night of 28.0321, at 23.30 hours, patient Lutchammah and his wife were ‘wansfered from Tamassa Cente to New Soullac Hospital where they reached at 00.15 hrs (29.03.21). They were admited to a ward occupied by themselves and another patient, ramely Inte Mr Beedassy. Mrs. Lutchammah stated that they were left unatlended without any eae. Mrz. Lutchammah informed the committee that Mr Beedassy who had a recent leg amputation kept on sereaming with pain all night. She further stated that there was no pee Pagesof7 yewtention from the staff, nor was there any provision for medication or water. Mrs. Lutchamma had to help Mr Beedassy herself on several occasions, She stated the ward was filthy and smelled bad 10.MrLutchammah had missed his Dialysis session on Saturday 27 March 2021. After the reopening of the Dialysis Unit following fumigation all sessions were rescheduled ‘Mr Lutckammah hada catch up Dialysis in the moming of 29.03.2021 at 07.00 am. ‘According to Mrs. Lutchammah, the Dialysis session was shortened to 2 curs and patient ‘was taken back to the ward. During that same session, Mr Beedassy had collapsed and passed away. She and her husband were the only occupiers ofthe ward and though her husband was ‘at wel, he was not provided with proper medial and nursing car, 11. At interview, Mr Hawaldar Jayesh and Mrs Sunassce Kresny explainet that they were ‘the only two Nursing Officers on duy at Souillae Hospital on the night of Sunday 28.03. 2021 and Monday 29.03.2021 In fact, Soullae Hospital had been closed down on 27 March 2021. In the afternoon of 28 “March, they along with @ Dr Awalar and an attendant were sent to open the Wards and to receive Dialysis patients who were tested postive from Tamassa Cente They stated that when they reached Soullac Hospital in the afternoon of 28 March 2021, they had a lt of difficulty to arrange for the reopening of the wards where they hai never worked before. They had to look for the equipments and apparatus, which they recuperated from dillerent comers of the hospital, All the support departments such as the Pharmacy, procurement office and Kitchen were closed down ‘They had been asked by the Regional Nursing Administrator to provide nursing care to the CCovid positive Dialysis patients in the wards, and as wel, to perform Dialysis sessions on them. {A frst batch of 12 patients ffom Tamassa Centre were edmited to one ward st around 19.00 hous. A second ward had to be opened to receive Mr Beedassy and the Lutctammah couple at around 23.30 brs. {At midnight, they took 10 of the patients tothe Haemodialysis Unit on the ground floor for their Dialysis sessions, An entry in the Dialysis Occurrence book confirms that the Dialysis tended at 230 hours and after disinfection, the Unit was closed down at 3.09 hours (on 29 ‘March 2021). ‘A few hours later, at 6.30 hrs, they again opened the Dialysis Unit and shifted four patients from the ward, including Mr Lutchammah, for Dialysis which was scheduled at 7.1S hours. Both Nursing Officers explained that while they were busy in the Dialysis Uri, they had no choice than to leave the patients inthe two wards under the care of an attendant. At interview, both the Nursing Officers stated thatthe tasks were dificult in view of several ‘constraints and by next moming they were exhausted withthe load and long hours of work. pagesot7 Lew (MPI Ce pore‘They admitted that though they did their best to deliver, the standard of care was not asin normal times. 12, On the same night of 29.03.2021, at around 23.00 hrs, the condition of Mr “Lutcharamah, who had not been well all day, deteriorated. He was attended by the Dr Awotar, MHO. At 1.00 am (30.03.2021), it was decided to tansfer him to ENT Hospital by the SAMU team as no ICU care was then available a that time at Soullae Hospital and hence the transfer was effected much later at 05.00 hous. AYENT Hospital, after investigations, he was diagnosed to be in Septic Shock and managed accordingly. Despite intensive weatment at the ENT hospital and in view of the serious ‘comorbidities, the patent's condition remained crtcal. He collapsed and passed away on '31,03.21 a 17.00 hrs with Septic Shoek, ‘Mas, Latchammah, who had been left behind at Souillac hospital, complained that she was ‘not informed about the deteriorating condition ofher husband at ENT. Conclusion: 1. I appears more probable than not that Mr Lutchammah had already been infected to Covid-19 on or about 20.03.2021 when he fist felt unwell. His symptoms were negligently ignored at Chemin Grenier AHC and a the Souillc Dialysis Unit which he Fad attended 09 23.03.2021 and on 25.03.2021 respectively. No PCR test was eared out despite the Covid ‘outbreak et that time, Ivis regrettable thatthe staff failed to adhere tothe existing protocol. It was much later on 26.03.21 when the patient and others were quarantined that & PCR test was carried out and ‘the report made available on 28.03.2021 2, The mix up of the PCR Test reports on 28,0321 for Mr and Mrs. Luchammah was ‘unfortunate and led to unnecessary transfers of fail patient from Tamasse Cente to ENT and back, Asa fact, Mr Lutchammah was the one who was Covid-19 positive. 3, The committee deplores the fact that sick patents including Mr transferred toa poorly staffed Souilla Hospital inthe middle ofthe night. Latchammah were 4, It isa fact that Mr Lutchammah did not obiin the required Medical and Nursing care ‘when he was admitted at Souillae Hospital on 28.03.21. The complaints of Ms. Lutchammah are fully justified. (see para 11 under observations) 5. Inview of the above, the Ministry may be minded to refer the following officers to ‘the relevant authorities for any further enquiry and action: i. ‘The Nursing Omficers on duty at Chemin Grenier AHC and New Soullac Hospital Dialysis Unit on the 23 and 25 of March 2021 respectively, in that dey faled to take ny action as per sanitary protocl then in force.fi, The Officers who took the decision to quarantine the Dialysis patents at Tamassa Centre without ensuring himseifthemselves of the provision of adequate staf and logistic support, and for not having considered the Dialysis patients as vulnerable ‘subjects who needed special medica cae and attention. ‘The committee tkes note of the repeated statements of Dr G. Deepchand, RPHS, during his interviews tothe effect thatthe decision to quarantine dialysis patients at ‘Tamassa Centre was taken “dep a haut iil, "The Transport Officer and Dialysis Coordinator for failure to provide tasic comfort to patients including late Mr Lutchammah during their transfers from their respective residence to Tamassa Centre, iv, The Regional Nursing Administrator and Dialysis Coordinator for their failure to arzange for adequate staffing atthe Tamasse Centre and atthe New Souillac Hospital Dialysis Unit and Isolation Ward ‘The Committe is unable to specify the name of Officers concerned given thal the its request, to the Ministry for the communication of relevant names hes had no response. ‘Name Designation | Date ‘Signature | WicL Nuckchady | Chairperson [23 Feb 2023, H- | DrK Boodhoo Member [33 Feb 3023 DeS. Poor Meniber | 33 Feb 2023 DER. Goordoy% Meniber [23 Feb 2023 Mri. D. Bhijohany | Secrtary [23 Feb2005 Page 7 of 7Enquiry No ase of late Mrs Sarofinee RAMSAMY ‘The Ministry of Health and Wellness has requested this committe to carry out an enquiry into the cases of 11 deceased patients who were on regular Haemodialysis st New Souillae Hispital and who were exposed to Covid-19 infection, Late Mrs 8. D. Ramsamy was quarantined at Tamassa Cenze on 26 March 2021. She was tested positive for Covid-19 on 9 April 2021 and transferred to New Souille Hospital. She passed away at New Soullae Hospital on 21 April 2021 at 10.40 hrs ‘Complain In a press article in Week-Fnd of 3 April 2022 and at interview the husbard of Mes S. D. Ramsamy, Mr Cenabedy Pillay Krishna Ramsamy, and the daughter in law, Mrs Vanessa \Velord stated inter alia that ‘a. An ambulance which was arranged to pick the late patent st 10.30 hrs for Tamassa Centre on 26 March 2021 arived at midday and took the patient t0 Souillac Hospital. “Mush later at 17.00 hrs a CNT bus conveyed her to Tamassa Centre ‘The husband was not allowed to accompany his wife. ‘The food served to the Inte patient was unpalatable. ‘The Dialysis was not done appropriately and as regularly ‘They were not allowed to sce the corpse oftheir relative and raised daults as to the true ‘dentiy ofthe corpse in the closed coin Summary of ease: Mrs SD. Ramsamy was a known case of Diabetes Mellitus, hypertesion witk Chronic Renal Failure. She was on regular dialysis at New Souillac Hospital thrice weekly on Mondays, ‘Wednesdays and Fridays since December 2008. She was admitted on several occasions at J. Nehru Hospital for Anaemia, uid overload, ‘Avil Fibrillation and was treated accordingly. (On 25 March 2021, a Dialysis Nursing Officer at Souillae Hospital was detected Covid-19 positive. All those patients attending Dialysis atthe Unit were considered tobe potentially exposed to Covid-19 and the Ministry of Health decided to quarantine all of thm, Late Mrs S.D Ramsamy being oe of them was quarantined at Tamassa Cente on 26 March 2021 ‘Along with other dialysis patients she had been conveyed from Tamassa Centre 10 Souillac Hospital fr dialysis on 29° March, 31" March, 2% April and $ April 2021 Her PCR Covid 19 test was negative on thee occasions, 27" March, 2% Ail and 4 April 2 (On $ April 2021 while undergoing her routine dialysis session at Souillac Hospital, she had chest pain and palpitation witha fast Atrial Fibrillation (AF), She was transfered urgently by Mme DBthe SAMU team to J. Nehru Hospital TNH) and was admited tothe Isolation ward 0-4. After tweatment the fast AF was reverted to Normal Sinus Rhythm. Dialysis was done at SNH on 7® ‘April 2021, On 08 April 2021, she was discharged from the isolation ward of JNH and was transferred back to Tamassa quarantine centre (0n09 April 2021, she hada session of dialysis inthe morning and the same evening she was tested positive for Covid-I9. She was hence transferred to the isolation ward at Souillae Hospital and managed accordingly. At Souillac Hospital, from 09 to 13 April 2021, she had few episodes of diarthoeas and Ihaemoptysis and on 13 April, her SPO2 dropped to £2%. She vas shifted t ICU and was kept on oxygen. The Chest X-ay had shown patchy lesions without effusions The case was discussed on Zoom Platform amongst the Consultants ané the treatment protocol was revised. An antifibrinolytic agent (Tranexamic acid) and dexarethasone were added. Her condition gradually improved. From the documents available there is no record of any dialysis done om het from 10 to 13, Apri but on 14 April she underwent dialysis fr 4 hours, On 19% April while undergoing her dialysis session, she had an episode of hypotension and she collapsed. She was resuscitated and admitted to the ICU. She was kept on ventilatory support and on Inotopic drugs. ‘The son was informed about the general citial condition ofthe patient onthe same night at bout 20.00 hours by Dr Hurgobi, Anaesthesiologist. (On 20April, Mrs Ramsamy was conveyed to ENT Hospital by the SAMU team for a Chest CCT Scan. It showed ground glass opacity in both upper lobes of the lungs with patchy consolidation. The case was discussed amongst the consultants on Zoom and it was decided to keep the patient on Ventilator ina prone position. In the morning of 21 April, Mrs Ramsamy had sudden cardiac ares at 9.00 brs and despite resuscitative measures she passed away and was declared dead at 10.00 hours. ‘The cause of death mentioned inthe ease file was Septic Shock as a consequence of Severe ‘Acute Respiratory Distress Syndrome (SARS Cov 2) ‘Methodology: ‘The following documents were scrutinized Patient's case file fom J. Nehru Hospital N 61434 Patient's case ile from NSH 180 007. ‘Tamassa Quarantine Centre Occurrence Book, Extract from the Occurrence Book of Souillac Hemodialysis Dialysis Usit List of Medical and Nursing Staff posted at Tamassa Quarantine Centre List of Medical and Nursing Staff posted atthe Souillac Dialysis Unit. Gh mmrnn QO ew fh‘The following relatives were interviewed: 1. MrCanabady Pillay Krishna Ramsamy, husband of late patent; and 2. Mrs Vanessa Velord, daughter inlaw of lat patient. ‘The following stafs were interviewed forall 11 case including the present ease; 41. DrDeepchand, Regional Public Heath Superintendent 2. DrSok Appadoo 3. Dr Karamject Sewshurn, Dr Naail Doomun and Dr Irvin Dookun, Medical Officers posted at Tamassa Centre. 4, MrRamgoolam, Nursing Officer in Charge at Tamassa Centre. 5. MrDev Rishi Bajeh and Mrs Nalini Lutchmun, Nutsing Officers, Tamassa Cente. 6. Mr Sachin Caunye and Mr Saad Sekunder, Dialysis Nursing Officers, in isolation at Tamassa Cente 7. DrRuchpaul, Medical Officer posted at Soullae Dialysis Unit 8. Mrs Ilakkoomee Callingee, Nursing Officer, Dialysis Uni 9. MrMohamad Reza Raheeman, Nursing Officer Dialysis Unit 40. Mrs Nisha Chureetur, Nutritionist 111, MrJugroo, National Dialysis Coordinator 42. DrPreetum Ancharaz, Nephrologst 18, DrCChiniah, Medical Superintendent, Souilae Hospital 44. De Oozceraly, nephrologis. 46, DeNilesh Soowamber, RRT Doctor ‘This list snot exhaustive. A fll sts annexed tothe introductory remarks Observations: 1. This Commitee takes note of the hardships endured by late Mrs Ransamy as from ‘the 26 March 2021 when she was quarantined and insolation at Tamassa Cente, 2. There are no clinical notes available to this Committee on the clinical health status of late Mes Ramsamy during her stay at Tamassa Quarantine Centre, as from 26 March 2021 Atimterview, the Nursing Officers at Tamassa Centre stated that, despite the acute shortage in rmanpovier, they did take the Vitals of Dialysis patients twice daily but they didnot record same on any monitoring sheet. Dr Doomun, Dr Sewchurn and Dr Dookhun who were also posted at Tamassa Centre stated ‘hat they had not recorded any of their clinical observations and findings, for any of the ‘quarantined patients including for Mrs Rannsamy. However, ftom information gathered through relatives of other deveased Dialysis patients, it appears that the Dialysis patients were left isolated in their rooms, without any asitance and with rae visits from the medical staf. Qt more S2-3. Late Mrs Ramsamy had several co-morbidities, DM, HBP, CRF and cardiac lanthythmia, She was on Losartan, Actraphane, Metoprolol, Aspitin, Atorvastatin and some ‘The personnel interviewed stated that Dialysis patients were required to bring their own ‘medication from home and in this eas, it cannot be ascertained whether the ate patient was able to obtain and did take her medication on time, 4, Late Mrs Ramsamy underwent Dialysis sessions on allemate days. Due to sanitary measures and disruptions atthe uni, she missed one session on 27 March but caught up on Monday 29 March 2021. She then bad her dialysis sessions on 31! March, 2* April and 5 April ‘She was admitted to JNH dve oa cardiac complication from the S* April to 8% April and had. ‘session of dialysis at INH on the 7* April ‘When she was transferred back to Soullac Hospital, she had her dialysis session on 9° April then on 14® and 19% April. From the ease fle, there is no entry or records of any dialysis carried out on the patent from 10 to 13 April and from 15 to 18 April 2021. There is no explanation for these missed sessions. The dialysis sheets ofthe patient have gone missing and are untraceable. This Committee ad ho means to know the state of health of Mrs Ramsamy before and ater each of the Dialysis At inerview, Dr Ruchpaul, MHO/SMHO, as well asthe Dialysis Nurses on duty maintained that the Dialysis sessions were carried out in conformity with the established practice. The sessions were supervised by a Nephologis. 5, Late Mrs Ramsamy collapsed while undergoing dialysis on 19 April. After siocessfil resuscitation she was admitted tothe ICU and kept on ventilatory support. Her condition remained eritieal and despite the intensive management, she pased away on 21 ‘April 2021 ‘ACCT sean chest carried out on 20 April 2021 had shown the classical picture of severe Covid-19 infection The Cause of desth was mentioned as septic shock as a consequence cf severe acute respiratory distress syndrome due to SARS-COV 2. The corpse was disposed a per sanitary protocols existing a that time, Conclusion: |. tis an undeniable fact thatthe patient had not bosn adequately monitered and did not receive the required care and attention while being quarantined at Tamessa Centre. This was due tothe inadequate number of Medical and Nursing Officers posted atthe Centre during ‘the iil days and the complete lack of supervision. Ho mn LEO2. The management ofthe late patient at Soullac Hospital as from the (S April 2021 up ‘until her demise cannot be faulted in that she was properiy managed and treated as per then existing protocol Nevertheless, the Ministry may be minded to refer to the proper Authority to cary out ay investigation into: i, The Officer’s who took the decision to quarantine the Dialysis patons at Tamassa Centre without ensuring himselithemselves of the provision of adequate saff and logistic support, and for not having considered the Dialysis patients as vulnerable subjects including (Mrs S. Ramsamy who needed special medical are and attention. ‘The committe takes note of the repeated statements of Dr G, Deepehand, RPHS, during bis inmerviews tothe effet that the decision to quarantine dialysis patents at Tamassa Centre was taken “dep daha” ii, The Transport Officer and Dialysis Coordinator for flue to provide basi comfort to patients including late Mrs Ramsamy during ther tansfers ftom their respective residence 0 ‘Tamassa Centre iil, The Regional Nursing Administrator and Dialysis Coordinator for their failure to ‘arange for adequate staffing tthe Tamassa Centre and atthe New Sauillae Kospitl Dialysis Unit and isolation Ward, ‘The Committe is unable to name the Offices as its requests for the provision of relevant list of ames tothe Ministry have had no response Name Designation [Date Senne WL Naekehady | Chaizpeson [2S FEO eK. Hoodoo Member | 23 Feb aoa |W Dr Pooran | Member 23 Feb 025. : MELL.D. Bhyjohanry | Secreiary [23 Feb 3005 im Glee ol Page Sof 5Enquiry No 7: Case of late Mr Azad ROMJHON ‘The Ministry of Health and Wellness has requested an enquiry into the cases of Eleven (11) deceased patients who were on regular Haemodialysis at New Souillac Hospital and who, {allowing exposure to Covid-19 eases, were quarantined at Tamassa Hotel Late Mr Romilion vss sent to Quarantine Centre at Tamassa Hotel on 26 March 2021 and as later transferred to Suillac Hospital on 2 April 2021 on being tested postive for Covide= 19, He passed away on 11 April 2021 with “SARS-COV? astociated with chronic kidney disease” Complaints: ‘Mas Bibi Noureza Romjhon end Mr Mubammad Ajmal Romihon, respectively the widow and son of the late patient were convened fora hearing by this Committe. They exprested their concern over the clinical management of the patient, the quality of meals served and a lack of communication onthe par of the health authorities. ‘They also deplored the fact that late Mr Romijn ho was then negative for Covid-19, was ‘made fo travel in an ambulance with Covid-19 positive pations, They suspected that Me. Romjhon had thereby been infected while being conveyed inthe ambulance, Summary of the case: ‘The clinical notes in the case file and in the different Occurrence Books are scanty and incomplete. The Committee had o rely on the several interviews with the faily and staf to father the following information. ‘Mr Romjhon Azad (DOB 05/02/1969) was first diagnosed with Renal flue in May 2014, ‘He was followed up atthe Medical Unit, J Nehru Hospital. As from August 2014, he was having regular Dialysis sessions at J. Nehru Hospital Dialysis Unit and therefer at Souillac Hospital Dialysis Unit (As from June 2015) Following exposure to Covid-19 cases, which was first detected amongst the RDU stalls at Souilla: Hospital on 25 March 2021, he was taken tobe isolated at the Tamassa Quarantine (Centre on 26 March 2021. He was tested Negative for Covid-19 (PCR) on that day (Day-0), aE Buw