REPORT OF THE FACT FINDING COMMITTEE ON THE DEATH OF RENAL DIALYSIS PATIENTS AT THE NEW SOUILLAC HOSPITAL sine esReport on Death of Renal Dialysis Patients at NSH Table of Contents ‘erme of Rlerence Methodology a a Doctors whe deposed bafore the Cont om a Pratt Rept nena = = Category 1 The Deceased Patients ~COVID Positive se Patient BEEDASSY Keerpanand ncn - —: Patient LUTCHAMMAL Latchummayah = 7 ry ent SUBRATTY Chandra Kuma Patient URIORE Habis. Pationt RAMSAMY Sarees. Patent SAB Dookooma Pationt ROMIHON Aad. Patient JEEBUN Mahadeva Patent JENA Avishna Parte. Plant HART Mean ‘category 2 The Deceased Patients ~COUID Negative 30 Patent BEES00 Dharanaad nnn = 30 Patient SURWON Suton sen BR a case of Mr Dslr Lesage, suring ass patent -COMID Pest aero Whether Al Exiting Sanitary Protocol hal ben fowl om ints wore cleted nnn Contin in which bass ‘Staffing and Equlpment of Diaysls Unt 3t NSH mn ‘Whether measures were taken for Vaecination of fam Recommendations sn Ast of AviatReport on Death of Renal Dialysis Pationts at NSH TERMS OF REFERENCE Following the death of twelve (12) renal dialysis patients at the New Souillac Hospital from 29 March 2021 to 21 April 2021, Government set up the present Fact Finding Committee with the following Terms of Reference: “To inqute nto, and report on: (a) the circumstances leading tothe renal dialysis patients at he New ‘Souillac Hospital geting infected by COVID-19 and whether they had received the appropriate treatment thereafter: (©) the circumstances leading o the death ofthe twelve (12) patients; (©) the conditions in which the dialysis patients were quarantined at ‘Tamassa Holel, including medical arrangement made for thelr dialysis (@) whether all existing sanitary protocols had been followed a the New Souilae Hospital and atthe quarantine facility at Tamassa Hotel; (c) whether the Dialysis Unt of the Now Souilac Hospital is adequately staffed and equipped to provide treatment to patients; (9 whether measures were taken to provide forthe vaccination of stall against COVID-18; (@)_ whether there has been any act of negligence which led fo the death ‘of any dialysis pationt; and ‘any matter ancilary to (@) to (9) sbove and to make appropriate recommendations.Report on Death of Renal Dialysis Pationts at NSH Methodology ‘The Commitee started is investigation by ist obtaining from the Ministry of Health and Wefness the riginal medical and dialysis fles of all the deceased patients and, thereafter, wrote other immediate relatives inviting them to come and depose before the Commitee. “The doctors, nurses and members of staf of New Souilac Hospital (NSH) who ‘were, in one way or another, in contac withthe deceased patients and involved intheirteatment a the said hospital and also those, who were attending to them érng thei quarantine at Tamassa Hotel, were wien fo and invite to depose before the Commies, ‘The Committee also considered requests from persons who expressed their wish to depose before it The following doctors deposed before the Commitee: LDF A, Seatapah, Acting Regional Health Ditector, Jawaharlal ‘Nehru Hospital (INH) Dr S. N. Sok Appadu, Medical Superintendent, New Ear, Nose and ‘Throat Hospital (ENT) i. Dr. Chiniah, Medical Superintendent, JNH Dr |. Dookun, Ministy of Social Securly, National Sofdariy & Reform Institutions ¥. Dr, Deepchand, Acting Regional Public Health Superintendent (RPHS), INH Wi. Dr K. Sewehum, Ministry of Social Securiy, National Soidanly & Reform Institutions vi, DFP, Gungah, Medical Superintendent, New Souiliac Hospital vil, Dr 1. Oozeerally, Nephrologst ix, FV, Awotar, Medical Meath Officer, NH Dr S.8.M, Gaya, Consultant Physician, JNHReport on Death of Renal Dialysis Pationts at NSH Dr, Deepchand stated that he is the RPHS for the District of Grard Port and ‘Savanne and he was in charge ofthe patients quarantined at Tarassa Hotel but he was physically posted at NH. However, since 07 Apri 2021, he was: present at Tamassa Hotel a.a facilitator and nursing officers were assisting him, He stayed at Tamassa Hole! unl 16.00 hours only and, ater he ff there was another doctor on call. He also stated that it was Dr Ruchpaul who was looking after the dialysis patients whist Dre Oree and Dookun were at the Hote! on @ permanent basis. Dr Deepehand further explained that, on 23 March 2021, patients were admitted ‘at Tamassa Hotel following a contact tracing exercise and, on 26 March 2021, it ‘was discovered that a female nursing officer working at NSH was postive. ‘Thereupon, the authorities looked for a place for the patients to be put in ‘quarantine and, in this context, Tamassa Hotel was chosen as its not far rom NsH. Upon a question putto himby the Committe, he stated that there was no writen protocot atthe time when the dialysis patients were admitted to Tamassa Hotel. Present Report ‘The Committee will deal with the case of each patient seriatim and with paragraphs (a), (b), (c) and (9) ofthe Terms of Reference together as they are interrelated, Thereafter, each of paragraphs (d), (e) and () wil be deat with separately. Observations and Recommendations will be addressed in the last part of this Report.Report on Death of Renal Dialysis Patients at NSH Parts (a), (b), (c) and (g) of the Terms of Reference CATEGORY 1 - THE DECEASED PATIENTS (COVID PosiTIve) 1. Ir BEEDASSY Keerpanand, aged 55 ‘This patient was tested COVID positve on 28 March 2021 and died on 28 March 202% His family did not depose bofore the Commitee. The deceased's wile was convened and she sent a letter dated 24 June 2021 to the Commitee stating that, after consultation with members of her family, she was not inerested fo depose before the Commitee. ‘Nonetheless, the Commitle has considered his cage and perused his medical fies. It has beon noted that Mr Beedassy was on haemodialysis since one (1) year and he was suffering fom diabetes and hypertension. Owing to his let foot infection, he was admitted at Jawahariall Nehru Hospital (JNH) on 08 March 2021. He was discharged against medical advice on 09 March 2021 and admitted at Clinic Muller where, owing to gangrene of his left foot, he had a left above-knee amputation on 11 March 2021. ThereaRer, he attended hs dialysis. ‘session at New Soullac Hospital (NSH) on 15 March 2021 when he was referred to the surgical unit of NH for folow-up of his amputation. He was soon by the surgical Registered Medical Officer at JNH with no complication from the surgery, Mr Beedassy was quarantined al Tamassa Hotel on 27 March 2021. He was found COVID postive on 28 March 2021 and was referred te NSH for admission and treatment According to Mrs Lutchammah, wife of patient Latchummayah Lutchammah, both Mr Beedassy and Mr Lutchummah were transported in a van to hospital ‘and they reached hospital at 00,15 hours on 29 March 2021, in an exhausted state, where they were put in a male ward. During the whol night, Mr Beedassy was in pain and nobody altended to him. At 07.00 tours on 29 March 2021, MeLatchurmmayah and Mr Boedassy were taken to the dialysis. unit and Mr Beedassy passed away within half an hour of dialysis. 5Report on Death of Renal Dialysis Patents at NSH Medical CarefReport Indeed, the hospital notes confirm the death of Mr Beedassy during dialysis at (08.03 hours after he collapsed at 07.31 houts and after resuscitation messures ‘were carried out ‘There is, however, no record in the notes ofthe oxygen saturation ofthe patient since his admission, ‘The Cause of Death as per Cetifcate issued on 29 March 2021 by te Ministry ‘of Health and Wellness is as follows: (@) Ischaemic Hear Disease, (@) Chronic Renal Fallure and (6) Diabetes. ‘The other significant condition contributing to the death as per the said Crificate ie COVID-19 positive, Mr Beedassy was mos likely COVID positive several days before admission to ‘Tamassa Hotel. He missed his usual dialysis session owing to closue of NSH ‘on 26 March 2021. Mr Beedassy was taken for dialysis on 29 March 2021 at 07.00 houre without proper check of his medical condition, There was no record of his oxygen saturation as he was probably alteady in full COVID crisis. Unfortunately, he died around half an hour after the start of his dialysis session. “There was a lack of medical and ether personne! italy at NSH as itwas open only for ealysis of patients with chronic renal failure end isolation of patients positive to COVID-19, The Committee has noted that altiough Mr Beedassy was in pain all night, nobody attended to him Furthermore, the Committee finds that there were certain shortcomings on the patt ofthe medical staff who failed to ascertain whether Mr Beedassy was ft for dialysis inthe morning of 29 March 202%. However, the Committee notes that there were no management guidelines at that time,Report on Death of Renal Dialysis Patients at NSH 2, lr LUTCHAMMAH Latchummayah, aged 71 ‘This pationt was tested COVID positive on 28 March 2021 and died en 31 March 2021. ‘The Commitee heard his wife and son on 22 June 2021. It transpires from thie deposition thatthe patient was having dialysis sessions three (3 fo four (4) times a week at NSH since one and a half (1) years. He had coronary bypass in 2014 and was algo under treatment for diabetes and hypertension (01 24 March 2021, he attended the local Community Health Centre (CHC) as he was suffering from a throat infection for which he was given honeyand mouth gergle. According to his wife, he may have been COVID positive at that te. His wife and his son also stated that he had his usual dialysis session on 25 March 2021 and, on the following day, NSH informed the family by telephone that he would have to go to Tamassa Hotel, Mrs Lutchamman decided to accompany her husband and, at 19.30 hours, they were picked up in a15-seater van which took them to "La Croisée", Chemin Grenier, where a bus was wating for them, Although the bus was ful, it stayed there until 21.30 hours when it finally started its joumey lo Tamassa Hoel, reaching there at around 22:30, hours. They had access to their room at 00.16 huts onthe next day. PCR tests were done in the moming of 27 March 2021. However, a onfusion arose as to whether twas Mr Lutchammah or his wife who was COVID postive. Mr Lutchammah was supposedly found positve and transferred to Ear, Nose ‘and Throat (ENT) hospital but, when he arrived at ENT, he was declared negative and was sent back to Temassa Hotel, His wife was then told that she was the one who was positve, However, upon the insistince of Mrs Lutchammah, PCR tests were repeated on Sunday 28 March 2024 and, at 23,00 hours, was confirmed that it was Indeed Mr Lutchammah who was COVIO positive and not his wife. Both Mr and Mrs Lutchammah were then taken to NSH in @ van in which Mr Beedassy, who was also COVID positive, was traveling. They reached 7Report on Death of Renal Dialysis Patients at NSH hospital at 00.15 hours on 29 March 2021 and they were putin a male ward. Mrs Lutchammah, who stayed in the ward, stated that, during the whole right, ‘Mr Beedassy was in pain and nobody attended to him wien he was calling out ‘8107.00 hours on 29 March 2021, Mr Lutchammah and Mr Beedassywere taken to the dialysis unit. Unfortunately, Mr Beedassy died within half an hour of dialysis and, as regards Mr Lutchammah, his dialysis lasted only two (2) hours ‘and breakfast was served at 14.00 hours. In the evening, Mr Lutchammah became agitated and breathless. The doctors ‘and nurses, who were on eal, attended to him and he was transfered to ENT hospital inthe early morning on 30 March 2021 by SAMU. Medical CareiReport Medical notes from NSH were not avaliable, but the Occurrence Book from NSH confirms Mrs Lutchammah's statement regarding her husband's deteriorating condition. The patient arrived at ENT hospital on 30 March 2024 at 6.00 hours with poor oxygen saturation (80%). He had atrial fiat and jaundice. He had tueatment for sepsis, steroids and cardiac support. CT scan was not serformed ‘owing to the patients condition and he, unfortunately, colapsed and died at 417.30 hours on 31 March 2021, “The Cause of Death, a per Certicae issued on 31 March 2021 by the Ministry of Health and Wellness, sas follows: (6) Septicaemia; and (0) Chronic Renal Failure on hemodiaysis, ‘other condition contributing to the death: SARS COVID 2 infectionReport on Death of Renal Dialysis Patents at NSH ‘The Commitee notes that Intensive Care Unit (ICU) facities were not ‘operational at NSH and, when MrLulchammaye's condition deteriorated during the night of 29 March 2021, twas only at 08.00 hours on 30 March 2021 that he was transfered to ENT hospital and he died on 31 March 2024 Undoubtedly, had NSH been equipped with ICU facies, this patientcould have followed treatment for dialysis as well as received tiely emergency are atone place. ‘The Commitee has reached the conclusion that systemic failure, nary fre to provide instant ICU treatment and facilis to the patent, has 10 a lorge ‘measure contibuted to the death ofthis patient. 2. Mr SUBRATTY Chandra Kumar, aged 59 Mr Subraty was found COVID postive on 27 March 2021 and died en 05 Apri 2021. The family chose not to depose before the Committe. His medical reports show that he was on haemodialysis on Tuesdays, “Thursdays and Saturdays since February 2018 and he suffered from diabetes, cardiac arhythmia and hypertension, He had hs dialysis on 25 March 2024 and was admitted in the iolation ward at JNH on 26 March 2021, after referral from CChamouny Community Health Centre for fever and chils. He had been prescribed antibiotics forthe fever. Medical CareiReport On 27 March 2021, he was slightly breathless and had diarthea, His PCR test ‘was positive for COVID and he was sent fo ENT hospital. On 28 Match 2021, he was transfered to NSH izolaon ward were he had his dialysis. On 02 Apri 2021, he developed a cough and fever with oxygen saturation of 82% and was, transferred as a very sick patient fo ENT hospital, where there were no dialysisReport on Death of Renal Dialysis Patients at NSH {acilties, The chest CT scan showed COVID pneumonia, score CTES (severiy score) - 20/25. The patient died on 05 April 2024 al ENT hospital just before he was due tobe transfered to NSH by SAMU presumably for his dialysis session. ‘The Cause of Death as per Catiieate issued by the Misty of Heath and ‘Welnessis as flows: (6) Chronic Atythnia; (0) Chronic Kidney Disease on haemodialysis; (6) Diabetes Type 2: (6) Hypertension; and {@) SARS.COV? Infection. Me Subraty was made to move to and from NSH and ENT hospital between 2 March and 02 Api! 2021, He had no calysis between 02 Apri 2021 and 05 April 2021 as there were no dialysis facilities at ENT. His condition deteriorated on 02 ‘April2021, when he was sent back to ENT hospital for ICU care, and be died on (05 April 2021 just before his transfer to NSH for dialysis, ‘The death ofthe patient ie undoubtedly due to systemic flue as there was a lack of coordination between the two hospitals resulting into failure fo provide timely and appropriate treatment to him. 4, UNJORE Habib, aged 73, Mr Unjore was found COVID positive on 02 April 2021 and died on 09 April 2021 1t tanspires from the meeting held on 22 June 2021 with his daughter, Mrs Keenoo, and his son-in-law, Mr Kesnoo, that Mr Unjre was having regular dialysis since 2015 at NSH, On 26 March 2021, the family was cortacted at ‘around noon and informed that Mr Unjore would be taken to Tamassa Hotel Mr Unjore was picked up at 18.20 hours in a van and taken to Souilac Youth Centre where a bus was collecting patients. 0Report on Death of Renal Dialysis Patients at NSH Mrs Keenoo state that her father was totally dependent on her moter and her mother insisted fo accompany him but her request was tuned down, Mrs Keenoo also sald that all the patients were packed in a 60-seater bus with no social distancing and the bus left for Tamassa Hotel after one and a half (1% hours). Mr Unjore entered his room at 23.30 hours and he telephored her and told her that he has been served “brn” and chocolate despite him being diabetic. Irs Keenoe further stated that Mr Unjore had to do his Insulin injection by himself and he was not sure if was done coneel. According to Mr Unjo apart from temperature taken atthe doorstep only, no blood tests were done. Fis frst POR test which was done on 27 March 2021 was negative. He had his dialysis session on 28 March 2021 at 28.30 hours and he was taken back othe hotel at 02.00 hours. He was conveyed to NSH for dialysis in an ambulance in which there were three to four patients, The dialysis session lasted only one and a half (1%) hours Instead ofthe normal three to four (3 ~ 4) hours (01 02 April 2021, Mr Unjore was found COVID positive and transfered lo NSH and he had no adverse eymptoms then. (On 06 April 2021, according to the family, he was confused when he talked 19 them over the telephone, (On 09 April 2021, Mr Unjore was breathless but the nursing officer came to attend to him only after one and a half hours (1%) ad slated that Mr Unjre had consumed too much food. (On Friday 9 Apel! 2021, Mr Unjore called his family every fve (6) minutes. He received oxygen and was sent fo ENT hospital for sean. On his return jouney to [NSH, he passed away inthe ambulance and was declared dead at 0020 hours on the next day that is, om 10 April 2021Report on Death of Renal Dialysis Patients at NSH Medical Care! Report ‘On day coven (7) POR testing, that is, on 02 April 2021, Mr Unjore was found positive for COVID-19 and he was transferred from Tamassa Hotel to NSH for, COVID-19 treatment. He also had his regular dialysis traatment thice weekly and was stable until 08 Aprl 2021 wien he stated to complain of shortness of breath. His oxygen saluralion was 92% before oxygen and his temperature was 37.8 degrees, Treatment on sleroids was stared and his ant-coagulation continued His condition deteriorated on 09 Apri! 2021 with oxygen saturation of 6% on at. CChest X-Ray (CXR), which was done in the morning, showed patchy pulmonary infltrates. Inthe evening, he was sent to ENT hospital for CT scan of chest, but unfortunately he died in the ambulance during his return to NSH and was declared dead at 00.20 hours on 10 April 2021 ‘The Cause of Death as per Crtficate Issued on 10 April 2021 by the Ministy of Health and Wellness is as flows: (6) chronic kidney disease; (6) diabetes Metitus; and (6) hypertension (other significant conaliton contributing fo the death: COVID-19 postive. ite Mr Unjote was found COVID postive on 02 April 2021, most likey owing to ‘contamination whilst being transported to Tamassa Hotel, when both positive and negative patients and staff ware mixed together nthe packed buses without proper sanitary precautions, [Although Mr Unjore's condition deteriorated on 06 April 2021, he was not attended to promptly when he was breathless and hypoxic. No ongen was ‘administered. This has also been confimed by other patients who wereadimitied namely, Mr Didier Lesage and Mr Roopun. The patiant was transferred to ENTReport on Death of Renal Dialysis Patients at NSH hospital in the evening of 09 April 2021 for CT Scan of chest but he died on his same evening way back in the ambulance on th ‘The Committee concludes that the death of Mr Unjore is mast likely to have occurred as @ result of failure to administer to him emergency treatment immediately upon the deterioration of his condition. The Commitloe has ‘accordingly found that there has been some negligence on the part of the hospital staff at NSH. 5. Irs RAMSAMY Sarodinee, aged 56 [Mrs Ramsamy was tested positive for COVID on 09 April 2021 and cied on 21 ‘Apr 2021, ‘The Committee met her husband Mr C.P Ramsamy on 22 June 2021, MrRamsamy stated that, on Friday 26 March 2021, his wife, who was an dialysis since twelve (12) years, woke up early in order to attend her usual dialysis session. However, at 07.15 hours, no means of transport came to pick her up. Later, she was picked up by ambulance and, at 10.09 hours, Mr Ramsamy was informed by telephone that al dialysis patients would have to 190 to Tamassa Hotel He added that his wife had her dialysis session at 11.00 hours and it lasted two ‘and half 2%) hours only. Ataround 17.00 hours, his wife and other patents were taken in a bus, in which there were twenty (20) people, to Tamassa Hotel. He was not allowed to accompany her. At the hotel, his wife complained about the food which was not properly cooked and she asked him to bring yogurt and @ few other things for her. (On Monday 05 April 2021, Hrs Ramsamy went for her usual dialysis at NSH but ‘Awas found that she had abnormal heartbeats, Her COVID test was negative She was admited at JNH, As she was not having her scheduled dialysis on Wednesdays, she had an intial dialysis of one and a half (1%) hours folowed by alate night dialysis starting at 2.00 hours and she returned to her ward at bReport on Death of Renal Dialysis Patients at NSH 102.00 hours on the next day. She was discharged and sent back fo Tamassa Hotel on 08 April 2021, (On 09 April 2021, she was tested COVID positive and was transfered to NSH as she was not feeling well (0n 11 Apri'2021, she was unwell and was transferred tothe Intensive Care Unit (CU). She had a CT scan at ENT hospital on 12 April2021. She was apparently wellon 17 Apri!2024 although she was stl sufering from dlarthea and she was, ‘ransferred back tothe isolation ward and was told that she was out of danger. However, she was not feeing wellon 18 Apri 2021 and, on 19 April 2021, she was transferred back to ICU. ‘According to Mr Ramsamy, she could not have her dialysis on that day as he learnt from a patent that the dialysis machine had broken down. (On 21 April 2021, he was informed by Dr Hurgobin that his wife was very sick She passed away on the same day. ‘The main complains of Mr Ramsamy are as follows: {a) that 2 COVID postive patient was in the same ambulance as hs wife; (6) that she could have been contaminated inthe ambulance or at INH; and {6) that she was never told tobe vaccinated against COVID-18. Medical carelreport Mrs Ramsamy was transferred from NSH to JNH on 05 Apri!2021, sufring from cardiac complications, PCR tests done on 27 March 2021, 02 April 2021 and 04 ‘April 2021 were negative. She was stabilised and transferred back to “emassa Hotel on 08 April 2021, However, she was found to be COVID postive on 09 ‘April 2021 and transferred to NSH. Her condition was stable until 12 April 2024 ven she was transferred tothe ICU because of low oxygen (SPO2 825 on at). CChest X-Ray showed patchy consolidation and she was referred for CT scan atReport on Death of Rena Dialysis Patents at NSH ENT hospital, She had slandard treatment for COVID-19 pneumonia, namely sterol, ant-coagulants and antibiotics. \When her condition improved, she was sent back to the isolation ward on {17 April2021, However, on 18 Apll 2021, her condition deteriorated wth oxygen saturation of 86% and she had tobe intubated on 20 April2021. Repeat CT scan at INH confimed COVID-19 pneumonia, Despite ICU treatment accorting to protocol, the patient died on 21 April 2021 “The Cause of Death as per Cetifcate issued on 21 April 2021 by the Ministry of Health and Wellness is as follows: (2) Severe Acute Respiratary Distress Syndrome due to SARS COV2; (0) septic shock Diabetes; (6) end stage kidney disease on diay: (2) diabetes Melts; nd (6) Hypertension. ‘ther signifeant condion contbuing to ha deat: Atl Faraion . 5. ris tomsomy Sorodjnes "Conclusion ofthe Commitioe aged sé [Athough Mrs Ramamy vas last ested negative for COVID on 04 Aor 2021, she was on 08 Api 2021 tested posve. The Committee notes that cne ofthe causes of death Is "Severe Acute Respiratory Distress Syndrome due to SARS COV 2" but when and where Mes Ramasamy was contaminated wit, COVID remains a guess. However, the Commie finds that there is substance in the version put before i that this could have occured during her tips to and om her eialysis sessions. ‘The Commitee therfore concludes tha proper timely treatment and protecton was not afforded toberReport on Death of Renal Dialysis Patients at NSH 6. Irs SAB Dookoomaneo, aged 64 ‘This patient's case is one of Chronie Kidney Disease (CKD) on Haemodialyss, Diabetes melitus typeI, Systemic hypertension. ‘She was found COVID positive on 27 March 2021 and dled on 11 Apri 2021 ‘She was first seen at JNH in August 2009 and was on haemodialysis since September 2014, She did dialysis thrice weekly at NSH and was provided with hospital ambulance to attend the dialysis sessions. Itis worth mentioning that inal this patent had refused dialysis forfour (4) ‘months when she was first advised to undergo same in April 2014. This Jformation is found inthe case sheet of JNH where the patient has signed and refused dialysis atthough all sks had been explained to her. Mr Laval Sab, the deceases's husband, deposed and stated that or 26 March 2021, his wife recelved a telephone cal rom the hospital informing her that bth Mr and Mrs Sab would be quarantined following detection of a COVID-19 positive case at NSH, Mrs Sab was effectively transferred to Tamassa Hote. Mr Sab also stated that, on 27 March 2021, his wife was found SOVID-19 positive and admitted In the isolation ward at NSH. He added that no dialysis ‘was done on Saturday 27 March 2021 and only one and half (1% hours of dlalysis was done on Sunday 28 March 2021, For the folowing two days, that, (0n 29 and 30 March 2021, no dialysis sessions were done. He also explained that Mrs Sab kept complaining about: () lack of television and telephone facities at Tamassa Hote and lack of sanitary measures in the Gialysis units; and () nursing staff wearing their masks with their nose exposed ‘orbelow the chin and some wearing "savate lepange", who kept moving in and cut for private errands. The dalyes patients were warned about talkingto people outsideDialysis Patients at NSH Report on Death of Re Mr Sab also said that he was not updated about his wife's heath siatus by the doctors and he could only communicate with her through mobile phone, Medical CareiReport Mis Sab was found COVID pasive on 27 March 2021 and transfered to NSH, (01 05 April 2021, her blocd oxygen was low (hypoxia). Antibiotics and steroids ‘wore stared and she was transferred to ICU at NSH, (0n 07 April2021, CT soan chast was done at ENT hospital, CTSS was 1228. (0n 08 Aprit 2021, her couition was stable and she was transferred fo the ward. ‘She was stable forthe folowing two days. ‘On 11 Apri 2021, she was found unresponsive, hypotensive, bradycardia (40 beats/min) SPO2 (oxygen saturation inthe blood) 60%. Resuscitation measures were caried out. She developed atial fbilation and was intubated and ventilated, CT-SCAN brain was requested. As scan facies were not avaiable at NSH, the patent was referred fo New ENT Hospital for same. Unfotunately, the patont collapsed in the evening. All measures to revive Mrs Sab fled, She was declared dead on 11 April 2021 at 20.30 hrs. ‘The Cause of Death ax per Crtfcae Issued on 11 April 2021 bythe Hinsty of Health and Wellness isa fllows: (6) Cerebrovascular accident with atrial viation; (0) Chronic Kidney Disease; and (6) SARS-COV? infection. sRonshinlan else connie ed Mrs Sab died from a Cerebrovascular accident and the contributory factors were Atrial bration and COVID-19.Report on Death of Renal Dialysis Patents at NSH 7. ir ROMJHON Azad, aged 52 He was found COVID positive on 02 April 2021 and died on 11 Apri 2021, Case of CKD, renal stones, hypertension (013 August 2014, Mr Romihon was inated on haemodialysis tice weekly at NSH, each cession lasting four (4) hous, He used to attend the lst session starting at 15.00 hours and used to drive to and from NSH all alone He was in ‘geod health and all his dialysis sessions had gone smoothly. Mrs Romjon deposed before the Committee and stated that, on 26 March 2024 she was informed that Mr Romjhon would be quarantined at Tamassa Hotel following diagnosis of a COVID-19 postive case inthe dialysis unit of NSH. An ‘ambulance picked him up at 20.00 hours instead of 13.00 hours as informed eatler. He was dropped at La Croisée, Chemin Grenier near the Avea Health Centre where other vans were bringing patients from other nearby regions. All these patients were subsequently accommodated in a bus and driven to “Tamassa Hole. MRomjhon later told her that the bus was fll of patents, there ‘was no social distancing and alady patient informed him that she wes COVID- 19 positive, Replying o a question putby the Committee as to whether she had any contact ‘wth the treating doctor, she answered in the negative and added thet the only tine a doctor called her was to announce the death of her husband. ‘According to her, no aparoprlate treatment was given to her late husband at NSH and the new team of nursing staff brought in to take over were perhaps inexperienced, She also stated that, in the van carrying patients to NSH for dialysis, there were both posive and negative COVID patients, |As per the medical notes, Mr Rhomjon was taken from Tamassa Hoel on 27 March 2021 for his fst dialysis.Report on Death of Renal Dialysis Pationts at NSH Medical Care/Report ‘Mr Ronyfion was tested postive on 02 April 2021 and sdmited inthe isolation ward at NSH where treatment was iiated. He had his dialysis session for only two (2) hours on that day, instead of four (4) hours, and he started 0 suffocate fon the folowing day. He was found hypoxic and was put on oxygen. (On 05 Apri! 2021, standard COVID treatment was inated (antbiobss, steroids and anticoagulants), (01 08 April 2021, he was comfortable on oxygen (SPO? with oxygen was 94 to (96%). CT-Scan Chest was advised, CTSS was 18/25. On 07 Apri 2021, the patient was stable and notin respiatory distress. ‘0n 09 Apri!2021, the patient was hypotonsiia wth blood pressure 97853, SPO2 174% on air and 95% on venturl mask. Noradrenaline infusion was started, He was stable on the next day but, on 11 April 2021, he became conlused and ‘wanted to pull ou his alysis catheter. He was reassured but that di not help. He longed for his family and kept on crying, He refused al injections and blood fests, He wanted fo have home food and refused all hospital food. Atempts by the family fo get food fo hin falled as the hospital had received stict orders forbidding any home cooked food within is premises. Food was prepsred inthe hospital and packed in take away boxes which were left atthe doorsteps and the patients had to collet the fod by themselves. Only clothes and water were accepted from outside, A psychiatrist was called and treatment was given. ‘At 20.45 hours, the patient was found drowsy wih rapid breathing (tachypnes). He was intubated and mechanically ventlated but, at 22.00 hours, he collapsed. CCPR test was done but the patient could not be revived and he was declared oad, ‘Tha Cause of Death as per Cetifcate issued on 11 Apri 2021 by the Ministry of Health and Wellness ie SARS-COV? infection associated with Chronic Kidney Disease,Report on Death of Renal Distysis Patients at NSH Conclusion of the Committee Mr Romihon was found COVID positive on 02 April 2021, most fkaly owing to contamination wailst being transported to Tamassa Hotel, when toth positive ‘and negative patients and staff were mixed together inthe packed buses without proper sanitary precautions. 8, ir JEEBUN Mahadeo, aged 57 Mr Jaebun was found COVID positive on 02 April and died on 11 Agr! 2021 His relatives who deposed before the Committee were:- 1. Mrs Jyotee Jeebun, wife of deceased; 2.Mr Ashvin Jeebun, son; and ‘3, Me Keshay Jaidev Hanzary, son inlaw, ‘They were accompanied by a panel of barristers, namely 4. Ms. Sornurn; 2.Ms A, Nunkoo; and 3, MEN. Busgopaul Mrs J, Jeebun stated before the Committee that her husband had been on dialysis since December 2013, He used to have three dialysis (3) sessions weeliy, namely on Tuesdays, Thursdays end Saturdays, each session lasting for three to four (3 -4) hours. He was traveling by public transport te and from the hospital. She also emphasised that he was a sherman and an active person who used to dive and ‘pose casiers” ‘She explained that, on Thursday 25 March 2021, he was picked up from his home in a 15-seater van for his routine dialysis session. He was the last one to board the van, which was full with thirteen (13) to fourteen (14) passengers, She further stated that, on Friday 26 March 2021, she heard on the redo that ‘one nursing oficer was tested COVID-19 positive at NSH and she also received ‘telephone call informing her that her husband would be quarantined for fiteen 20Report on Death of Renal Dialysis Patients at NSH (18) days at Tamassa Hotel as a precautonary measure and that an ambulonce ‘ould be picking him up at 12.30 hours. However, twas only at 17.¢5 hours that a feen (15) seater ambulance, full of passengers, picked him up. She noticed that the driver was wearing his Personal Protective Equipment (PPE) and all the passengers had thelr masks on Later, at about 19.30 hours, Mr Jeebun informed her that he was at "Balance, Surinam" where a bus was parked and waiting for patients from surrounding regions to be brought in. Mr Keshav Hanzary, the son-in-law of Mr Jesbun, deposed and stted that he went fo Balance, Surinam and he saw a bus of approximately sixty (60) seats’ capacity waltng. He noticed that (2) there were 25 passengers seated in the bus; (©) there was no social distancing (©) allwindows of the bus were closed; (4) there was no air conditioning: and {6) some ofthe passengers were not wearing their masks. ‘According to Mr Hanzary, the patents were left to themselves and NSH looked more like @ quarantine centre than a treatment centre Mc Hanzary further stated that at NSH there were no regular chects by the rursing staf. The latter would only accompany the doctors during thelr morning ‘and evening rounds. Whenever the nursing staff was called upon, they would assur the patents that they would be attended to shortly but his was never the case. Furthermore, food and drinks were lef at the doorstep ofthe isolaion ward to be collected by the patients themsehves, Mr Hanzary further added that, when he tried to obtain more information, there was no response to all his telephone cals and, eventually, he telephoned = higher officer ofthe Ministry of Health and Wellness to intervene on his behalf aReport on Death of Renal Dialysis Patients at NSH On is part, Mr Ashwin Jeebun, the son of Mr Jeebun, stated that ittook a lot of time to collect all the patients and the bus stopped at La Croisée, Chemin Grenier and at Riviére des Galets before finaly reaching Tamassa Hotel He emphasised that (athe whole trp took four () hours when normaly it would have taken only thity (30) minutes to reach there by car; (b) amongst the passengers in the bus, there were both positive and negative patients and (o) it was only at 23.30 hours tha his father reached Tamassa Hotel and was given a room by midnight. The later was very tired and was offered “brian” for dinner Mr Jeebun also added that: - 1) although Saturday 27 March 2021 was a routine day for bis father's dialysis, same was not done; ») on Monday 29 March 2021, his father's dialysis lasted for two and a half (2%) hours only instead ofthe usual four (4) hours; and ©) ashis father's room at Tamassa Hotel was situated onthe thir Noor and no lit was available, he had to climb all the way up and had afculty in breathing whit eimbing the sts Mrs Jeebun, on her part, mentioned that: (6) there were no TV and telephone facites atthe hotel (e)the patente only means of communication was though their mobile telephones; and {6) the food they were offered was sally ‘She further added that, through WhatsApp video call, she noticed that her husband's face was swollen and he told her that he was requested to clean his room and wash his own clothes duriag his say at the hotel, When asked by the Committee as to whether she could have stayed with her husband, she replied ‘that she was nether aware nor informed that she could stay with him.Report on Death of Renal Dialysis Patients at NSH [Mrs Jeebun also added that Mr Jeebun was very worried as (a) onepationt, wo hnad been doing dialysis together wih him, had passed away; (0) three other deaths were reported at NSH; (c) the persons who died were al COVID-19 positive; and (d) Si (8) patents were accommodated in the Isolafon Ward of [NSH and they were having dialysis for two (2) hours only instead o the routine four (4) hour sessions. Medical Care/Report ‘The patient was tested postive for COVID-19 on G2 Apri 2021 and was admitted In the isolation ward atthe NSH, However, on O7 Api! 2021, he was breathless with Fever Temperature 38.7°C, '$PO2 on air 82%, on oxygen 91%. Treatment was given, namely antiblots, anticoagulants, isotropic support and steroids, Oxygen (Oz) therary 3 to SLI minute, He was kept on venturi mask, CT-SCAN chest showed ground glass ‘opacties across both lung fields CTSS 18/25 (prognosis severe) (On 08 Apri 2021, the patient was in respiratory distress (SPO2 70 - 75%, PH 7:2, PO2 46 mm Hg), He was intubated and mechanically ventilated (IPPV). His family was informed about his health status. Mr Ashvin Jeebun sai that the ‘doctor fold them that his father's state of health was stable and requested the family to stay postive, On 09 April 202%, the patient had an episode of ventioular tachycardia (pulseless venticuar tachycardia), reverted to sinus (normal) rhythm after DC shock 200 joules, vitals were stabilised and dialysis was done, (On 10 April 2021, antibiotics were changed, blood tests were repested and he \was maintained on mecharical ventlaon. His relatives were informed about the stable heath ofthe patent aReport on Death of Renal Dialysis Patients at NSH However, on 11 April 2021, the patient went info ventioular fxilation and cardiac arrest, CPR was cared out but was unsuocessful. He was declared dead at 13.00 hours. Mr Henzary further stated that he requested forthe body of Mr Jeebun to be placed ina cofin provided by the family but his request was tuned down by he authorities, ‘The Cause of Death as per Certificate issued on 11 April 2021 by the Ministry of Health and Wellness is as follows: (8) SARS-COV? infection associated with Chronic Kidney Disease; ns (©) Diabetes Metitus; (6) Hypertension, "Conclusion of the Commitee Mr Jeebun was found COVID postive on 02 April 2021, most likely owing to ‘contamination whilst being transported to Tamassa Hotel, wen bolh positive and negative patonts and staff were mixed together inthe packed buses without proper sanitary precautions 9. brs JENA Avishna Parvatee, aged 38 [Mrs Jena was tested COVIO positive on 02 April 2021 and passed away on 19 ‘Apr 2021 ‘She suffered from Systemic Hypertension, Diabetes Melitus type I, Complete Heart Block (Cardiac pacemaker in situ inserted in 2012 and 2018), Diabetic ‘etinopathy, Chronic Kidney Disease. No relatives of Mrs Jena Avishna came to depose before the Committ. From Information received, her husband is abroad working on a cruise ship. Two letters dated 09 and 15 July 2021 respectively were sent by ADR iAvis de Receplion) bu were returned with the mention “Gone Away’ uReport on Death of Renal Dialysis Patients at NSH Medical Care/Report This patient was inated on haemodialysis on 03 March 2021. A two-way ysis catheter was inserted in the right intemal jugular vein under echo guidance at JNH and the patient was shortlisted fr construction of ay AV fistula ‘The patient was admited at Tamassa Hotel on 26 March 2021 folowing the detection of @ COVID positive case in the dialysis unit of NSH. AI dialysis, patients were quarantined and mass screening was done, Her frst PCR test was negative. The PCR test was repeated on 02 Apil 2021, seven days after ‘admission. The patient was tested positive and admited inthe Isolation Ward at NSH. Treatment was given, namely lovenox-anticoagulant and blood Investigations were requested. From 02 April 2021 to 04 April 2021, the patient was stable and close monitoring was continued. (On 05 Apri! 2021, the patient collapsed whilst undergoing dialysis (SPO2 75%, pulsetSé/mt and BP 230/100mm Hg). Immediate resuscitation was done and the anaesthetic team was called in, Dialysis was stopped. V steroids was given, ventilation was carried outwith ambu bag and high fow oxygen. SPO2increased to 99% and the patient was stablised. Pulse and Electrocardiogam were (006 Apel 2021, the patient was better, was talking normally, was up and about ‘and was reassured, She was referred to a cardiologist atthe New EN" Hospital for assessment of cardiac status. Same was done and reporled as normal, On (07 April2021, dialysis was continued. From 09 to 13 Apri 2021, the petiont was stable, (On 14 April 2021, the patient complained of abdominal pain. Dyspepsia treatment wae given and she recovered. From 15 to 16 Apri 2021 the patient was stable, afebrilo, SPO2 84-95% on room ar, and the pacemaker wes pacing welDialysis Patients at NSH Report on Death of Ret (On 17 Aprit 2021, the patient had haematemesis (vomiting blocd) and was admitted in ICU. Anticoagulant was stopped. Blood and Fresh Froren Plasma wore transfused, (0n 18 Apr12021, haematemesis persisted, Blood reeuls showed “Ho 9.8 grt, Platelets count 45000, Prothrombin time >100 seconds. Transtused Blood Packed cells x2 pints, Fresh flozen plasma x 2 units, Platelets concentrate x 6 units, (On 19 April 2021, dialysis was done (non heparinised) but patient was restoss, uncooperative, disoriented and had tobe restrained to avoid gating injured. CT- SCAN Brain was requested, SAMU was contacted to cary the pation to Now ENT Hospital and back, (On 19 April 2021 at 18.00 hours, the patient was stable with BP 13065, SPO 98% with oxygen 2Umn, pulse 62 fn. At 19.45 hours, the pationt went into sudden cardiac arest. CPR was cattied out but was unsuccessful after tity (30) minutes, ‘The pationt was declared dead at 20.15 hours. “The Cause of Death as per Cerificate issued on 20 April 2021 bythe Nini of Health and Wellness sas flows: (@) Cerebrovascular accent (©) ESRF (End Stage Renal Faure) on dalysis; and (©) SARS- COV2 postive. “Conclusion ofthe Commits Mrs Jena was found COVID positive on 02 April 2021, most likely owing to contamination whilst being transported to Tamassa Hotel, when both postive and negative pallets and staf were mixed together inthe packed buses without proper sanitary precautions. 6Report on Death of Renal Dialysis Patients at NSH 10, Mrs HART Nicole, aged 63 ‘This patient's case is one of 1. Systemic Hypertension 2. ESRD (End Stage of Renal Dialysis) on haemodialysis ‘She was found COVID positive on 02 April 2024 and died on 26 Aprii2021. Miss ‘Jennifer Hart, daughter of deceased, deposed on Tuesday 29 June 2021. She stated that her mother was on dialysis since 2016. Dialysis sessions were held thrice weekly on Tuesdays, Thursdays and Saturdays. Avan from the Ministy ‘of Health and Wellness used to pick her up from her reskience at Tyack to NSH land back, She was alvays the third person to be picked up and all sanitary precautions were taken inthe van, (0126 March 2021, she was informed by the authories that al daly patents, ould be quarantined at Tamassa Hotel as a COVID-19 posite case had been tect inthe cialysis unitof NSH and that @ hospital vehicle would pck up Mrs Nicole Hart at 13.00 hours, However, it was only at 17.00 hours that she was taken to NSH, whore a bus was waiting forthe patients. The patients from surrounding regions were also assembled and the bus drove to Tamassa Hole! 2.00 hours. Normally a tip from Tyack to Tamassa Hotel takes arcund tity (G0) minutes. At Tamassa Hotel, the patient felt very lonely. There were no {elephone or TV faites available, The only means of communication with her family was through her mobile phone. Miss Hart also stated that her mother complained about the qualty of food ‘offered and the manner in which itwas served, The food was lef at the doorstep tobe collected by the patients and, sometimes, itwas eaten by cats. No laundry vwas available and clothes remained diy. It was difficult for the patient to ‘manage all lone as she also suffered from diminished vision in both ees. She ‘adided that on Saturday 27 March 2021 no dialysis was done and the PCR test hich was done was negativeDialysis Patients at NSH Report on Death of Re Medical Care/ Report On Sunday 26 March 2021, dialysis was dane but venous access was dificult, AV fistula was thrombosed and not functioning. The patient was refered to the Renal Dialysis Unit at INH for further management and dialysis was done there. ‘The lastealysie was done on 01 Apri!2024 according tothe medical file at NSH, ‘She was tested COVID-19 positive on 02 Apri 2021 and was transferred tothe Isolation waed at NSH, From 02 April to 07 April 2021, the patient was stable and treatment was given for hyperkalemia and anticoagulants were started, (0n 08 Apri 2021, the patient had dyspnoea - SPO2 85% open alr. She was put ‘on oxygen therapy. (0n09 April 2021, she was sil dyspneic and tachypnetc. No venous access was lable and dialysis was not possible. (0n 14 April 2021, venous access was obtained, Dialysis was done forthree and ‘ahalfhours (3 %). The patient felt much better and she was no longer dyspnetc (0n 12 April 2021, COVID PCR day 10 test was negative. The patient was stable, On 16 April 2021, CT-SCAN chest was done and it revealed ground glass ‘appearance and linear atelectasis of eft lng field. ‘On 17 April 2021, COVID PCR day 15 test was negative, The pationt was stable but no dialysis was done as AV fistula vas blocked. The patient was dcharged and advised to follow treatment at JNH. She was happy to be back hone. Only palliative treatment was prescribed by the Nephrologist (020 April 2021, according o her daughter, ner condition started to deseriorate, Dialysis could not be done as she was ted and unable to walkReport on Death of Renal Dialysis Patents at NSH (0n 27 Apri 2021, the patient was referred to JNH as she was off lysis for two (2) weeks. Only palative treatment was administered. COVIO-19 POR test was ‘repeated and was negative. She was complaining of dyspnoea (SPO2 93%, BP 170/100, Crepittions on both lung feds), Condition: Poor prognosis and imminent demise. Patients case was explained to relatives (son and daughter), (On 28 April 2021, SPOR was 97% open air, BP was 125/85. The patent was. wel In the moming but became hypotensive with BP 90/60 during the day and had no response to touch and verbal commands. She was semicorscious. ‘At 19.40 hours, she collapsed. CPR was carried out but was unsuccessful. She was declared dead. At 20.30 hours, Miss Jennifer Hart, the daughter ofthe deceased, was informed, ‘The Cause of Death as per Certificate issued on 28 April 2021 by the Ministry of Health and Wellness is 2s flows: (2) End Stage Renal Disease (ESRD); and (©) Hypertension, _ Conclusion of the Committee Mrs Hart was found COVIO postive on 02 Aptil 2024, moet likely oing to ‘contamination whist being transported to Tamassa Hotel, when both postive and negative patients and staff were mixed together nthe packed buses without proper sanitary precautions, »Report on Death of Renal Dialysis Pationts at NSH. CATEGORY 2 - THE DECEASED PATIENTS (COVID NEGATIVE) 1. Mr BEESOO Dharmanand, aged 54 Mr Beesoo's case is one of CKD, diabetes melitus type Il, Systematic hypertension, Epilepsy. Mrs 0.0. Beesoo, wife of Mr D. Beesoo, deposed before the Commitee. She slated that the patient was on haemodialysis since March 2020. His dialysis seselons were thrice weekly on Tuesdays, Thursdays and Saturdays. He was labetic type Il since 2015, He was provided with hospital ambulance to and from the dialysis unit (On 26 March 202%, offcials of NSH informed the patient that, flowing the detection ofa postive case of COVID-19 among the staff ofthe dialysis unit all Glalysis patients would be quarantined at Tamassa Hotel He was alo told that 18 van would pick him up at 10,00 hours. but it was only at 20:30 hours thet he was picked up by a van full of patients, some of whom were wearing masks whilst others were not. The van was driven to Choisy fist to pick up othr dialysis patients and then to Tamassa Holl, reaching there at 22.00 hours At the hotel, Mr Beesae complained about lack of telephone, TV and Internet facies, The only way he could communicate with his family was tough his ‘mobile telephone. Food was another problem and, at a certain polntin time, he stopped taking the hotel food, He requested for home feod but same was refused _as no cooked food was allowed inside the hotel premises. His morale was down and he fel that he was being jailed at Tamassa Hotel Ire Beee00 also sald that, on one occasion, her husband compbined of headache and, deepite three calls made, no doctors visited him. He bepged his family to get him out of Tamassa Hotel, otherwise he had the feeing that he ‘would die sooner or late. She aso stated thatthe patent's dialysis sessions at NSH were not done on a regular basis and the duration of dialysis sessions was ‘also shortenedireduced. Mis Beesoo recalled her husband teling her that 0Report on Death of Renal Dialysis Patients at NSH lalysis patients were scolded by the nursing staf and they were asked not to ‘speak and to wear their masks properly whist, onicall, the nursing staff were not wearing theirs. (0n 26 March 2021, Mr Beesoo's POR test was negative and, on 04 April 2021, his POR test was again negative, His lat alysis session was done on 06 April 2021 and he was retumed to the hotel at 1640 hours. These was no communication between Mr and Mrs Beesoo during that night, At 2.00 hours, hhotol rounds were done by nursing staff and no problems had besn reported. (007 April 2021, at 08,00 hours, there was no response from the pationt when he was called upon. Eventualy, he was found dead In his room ina siting postion. Mrs Beesoo further stated that her neighbour, a Police Officer, was already ‘aware of her husband's death whilst she was only informed much leer by the Minty of Heath and Weilnase and that his funeral was organised bythe state, “To a question put to her, se replied that her husband was totaly independent. ‘She also stated that, according to her, the two major causes of his death were lack of food and the stress suffered by him, ‘The Committee notes that Mr Dharmanand Beesoo dled twelve (12) days after being admited to Tamassa Hotel, The Cause of Death as per Certificate issued by the Ministry of Heath and Wellness is Chronic Kidney Disease (CKD) FyReport on Death of Renal Dialysis Patients at NSH 2. Ilr SURWON Suren, aged 64 ‘Mr Surwon's ease is one of Chronic Kidney Disease (CKO), High Blood Pressure (HBP), Diabetes Metitus type I ‘The wife and son of Mr Surwon deposed before the Commitee and stated that the patient was on haemodialysis since the last two years prior to his death and that he was not vaccinated. It transpires from ther deposition that all his dialysis sessions were done thrice weekly al NSH. Most of he time he was using hospital transport to ard from the dialysis unit and, sometimes, his son and daughter used to leave him atthe hospital, Prior to his passing away, he was independent and the dialysis sessions were going on smoothly, At one stage, his AV Fistula was not functioning and a dialysis catheter was placed in his right jugular vein and dialysis was continued (0n 25 March 2021, dialysis was done for thee (9) hours. On 26 March 2021, he ‘was informed thet, folowing the detection of a positve case of COVID-19 amongst one ofthe staff of the dialysis unit of NSH, all dialysis patents would bbe quarantined at Tamassa Hotel. A hosptal vehicle picked him ur at 17,00 houts and he was driven to NSH where he had to wait for about the to four hours for other patients to be brought in from the surrounding regions. Finally, they were all put in a bus and they reached Tamassa Hotel at 2.00 hours. “There was no socal distancing in the bus and only some patients were wearing masks whist others were not (On 27 March 2021, NSH was closed and no dialysis sessions were done. Mr Surwon's PCR test was negative. On 28 March 2021, his dialysis was done late at night ducing the last session. He retumed tothe hotel at 2.00 hours, The nursing staff helped him fo get back to his room, He was given tea and biscuits and was placed on his bed. The members of his family dd not have any contact with Me Surwon after his dialysis 32Report on Death of Renal Dialysis Patients at NSH ‘The next moming, on 29 March 2021, when they tied to contact him, there was. no response, He was found unresponsive on his bed at 07.00 hours during the rmotning round. CPR was trled but was unsuccessful. He was declared dead at (08.00 hours. and he was referred t the Police Medical Officer for post-mortem. ‘The deceased's son also stated that he had already loamt about his father's “death well before the doctors posted at Tamassa Hotel informed him. Infact, the ‘son complained about the fact that the medical team did not show any ‘compassion for the deceased's family as thay failed to inform therr about the death as soon as possible To a question putas to why nobody for the family accompanied MrSurwon in quarantine, the son replicd that he was not aware that relatives could ‘accompany the dialysis patents at Tamassa Hotel and itwas only later that he leamt about that on the rado, The son also queried why dialysis patents were ‘ot monitored between 23.00 hours on 28 March 2021 and 07.00 hurs on 28 March 2021 The Cause of Death as per Certificate Issued by the Ministy of Health and Wellness is as flows: (a) Chronic Kidney Disease: (0) Hypertension; and (6) Diabetes Metitus »Report on Death of Renal Dialysis Patients at NSH (Case of Mr Didier LESAGE ~ Surviving Dialysis Patient at NSH ~ COVID Positive Mr Didier Lesage wrote tothe Commitlee to express his wish to depose and the Committee agreed to his request. Mr Lesage stated that he is a diabetic pationt and has been undergoing haemodialysis at NSH thrice weekly on Tuesdays, Thursdays and Saturdays for the last six years, He added that everything had been going on well since he started dialysis in 2015. in fact, he even praised the dialysis unit and the personnel for their care and understanding With regard to vaccination, he tated that he was vaccinated with the frst dose against COVID-19 on 15 March 2021 and added that, out of ninety-si (96) patients under dialyels at NSH, only two (2) were vaccinated, He went on to explain that problems started wih the outbreak of the second wave of COVID-19 in March 2021. One female nursing staff inthe dialysis unit ‘at NSH was tested postive on 25 March 2021. On 26 March 202° at 13.00 hours, he was informed by the hospital that all dialysis patients would be ‘quarantined at Tamasea Hotel. He was picked up at 17.00 hours in an ‘ambulance but he was not taken directly to Tamassa Hotel. Instead, he was taken to Britannia and left there, Six persons travelled together inthe ambulance land all were wearing face masks, Other people had already gathered at Bitannia and he could recognise other dalyss patients among the crowd, Some were wearing face masks whilst others were not and there was 10 social distancing, (ther patents and relatives were also brought in from Camp Diable and Rive ddu Poste. At around 21.00 hours, two buses collected these patients and relatives, Around one hunéred and forty (140) persons were packed in both buses and there was no social distancing, Some of them were sick and others ere tired. They were left without food and drinks. uReport on Desth of Renal Dialysis Patients at NSH ‘The buses didnot drive directly to Tamassa Hotel, They stopped all long the way at Tyack, NSH, Surinam and Chemin Grenier to collec other patonts and they nally reached Tamassa Holel at 22.30 hours. Aer registration, they were ‘each allocated a room but no food and drinks were provided to them. Many of them slept on an empty stomach whist others were offered "brian, a mes! not ‘advised for dialysis patients. The folowing day, they were offered bacon and eggs for breakfast and the food was salty. Complains were made to the hotel management tut nothing c’changed. He was also told that there would be nobody to clean his com and he ‘would have to do the cleaning himsel. He had a frst POR test on Saturday 27 ‘March 2021 and the test was negative, No dialysis was done on that day a the Gialysis unit of NSH was closed for general cleaning and steiisation. (On Sunday 28 March 2021, some patients were tested positive for COVID-19 ‘and shited tothe isolation ward at NSH. Dialysis resumed on that Sunday and fourteen (14) patients, amongst whom some were COVID-19 postive, traveled though everyone was wearing @ in the same ambulance. He also stated that, ‘mask, there was no social distancing, He added that, at NSH, the COVID positive patients were cialysed fis, folowed by the negative patients in the same unit. Dialysis sessions were shortened to two hours only. He did enquice about the way dialysis sessions were being ‘conducted and he was told that there were too many patients to be dalysed on that particular Sunday and the instructions came from higher quarters (Liorre vine depila haut). He further stated that dialysis sessions lasted tl late at night and all fourteen (14) patients ware brought back to Tamassa Hotel together in one anbulance only. There was no food kept for them at the hotel and many went to sleep on ‘an empty stomach whilst others had biscults and water only. Mr Lesage also sai that, after dialysis, the patients usually feel weak and hungry but, when they reached the hote, twas dark inside the compound and hey had 35Report on Death of Renal Dialysis Patients at NSH to fond for themselves as no assistance was avaiable. They had to help one another in order to reach thei respective rooms. Thus, many of them felt ist and frustrated but they tried their best to keep going as they knew they had no ‘other option (0 02 Apri 2021, Mr Lesage was tested COVID-18 positive and he was shied to the Isolation Ward at NSH, where other patients including Mr Unjore, Mr Romion, Mr Keenoo and Mr Roopun, amongst others, were also ‘admitted at the same tim. He added that it was not easy for them to stay inthe Isolation Ward as: (@) there were no doctors on cal; (©) the doctore would simply attend fo them briefly once daly and go away: and (6) no nurse was present inthe isolation ward; and (6) patients were ft on their Ir Lesage also made the following observations: >> ‘The [solation Ward was nol cleaned asthe whole hospital was closed and allstoff were quarantined, > Bed sheets were not changed regula. > Three ciaysis machines broke down after 2 April 2021 and all dialysis sessions were reduced to two hours only and were done alter two days instead of aerate days. Only two (2) nursing staf were present to care for about eighty-four (84) patents. It was only after 07 Apr 2021 that more nursing staff and dodors were provided and things retuned to normal. However, by that time more clalysis patients had passed away inthe isolation ward of NSH, ‘Only one toilet was avaliable and pationts had to clean it themsalves. Food wa’ eftat the doorstep ofthe Isolation Ward and was ustaly cold ‘There was shortage of mecical personnel Patients had dificully in obtaining prescribed drugs. 36