The Commission on Administrative Justice (Office of the Ombudsman) has invoked its suo moto powers to initiate an inquiry into the alleged deaths of three patients at Coast General Teaching and Referral Hospital. This investigation follows reports in the media that the deaths occurred due to a disruption in the oxygen supply, allegedly linked to scheduled maintenance at the hospital’s oxygen plant.
As part of its investigation, the Commission has directed the hospital’s CEO to provide a detailed report on the full schedule of planned maintenance activities for the oxygen plant, covering the period leading up to and including the date of the alleged disruption. The Commission is particularly focused on understanding the procedures followed in planning and executing the maintenance, including any risk assessments conducted to assess potential impacts on patient care, especially for patients reliant on oxygen therapy.
The inquiry also seeks clarification on whether the hospital had alternative or backup oxygen supply systems in place during the maintenance period. If such backup systems existed, the Commission demands an explanation as to why they failed to effectively address the disruption, if indeed they were operational but insufficient. This aspect of the inquiry is crucial to determining whether the hospital had sufficient contingency plans to safeguard patient care in the event of an oxygen supply issue.
Furthermore, the Ombudsman is requesting the hospital to provide a clear outline of the steps being taken to ensure that patients’ rights to timely and adequate healthcare are respected. This includes the immediate assistance from medical personnel during emergencies, which is fundamental in maintaining patient safety and ensuring that the hospital meets its duty of care obligations.
The Commission has also asked for a comprehensive report on the hospital’s treatment protocols, internal policies, and enforcement mechanisms, with a particular focus on how the hospital maintains and backs up critical medical equipment, such as oxygen supply systems. This would shed light on the adequacy of the hospital’s preventive measures, internal controls, and response mechanisms to ensure the reliability of vital medical services.
In addition, the inquiry seeks to understand the hospital’s incident reporting and investigation procedures that were triggered in response to the oxygen disruption and the subsequent deaths. The Commission has requested specific information about the actions and responses of medical and maintenance personnel who were on duty at the time of the alleged incident. The aim is to assess whether there were any lapses in the handling of the situation and whether proper protocols were followed.
To enhance accountability and avoid a recurrence of such a tragedy, the Commission has asked the hospital to provide an action matrix that includes any disciplinary actions being considered against staff members involved in the planning, execution, or response to the maintenance work and oxygen supply failure. This will ensure that the hospital is held accountable for any negligence or failure to comply with established protocols and procedures.
Lastly, the Ombudsman has requested the hospital to outline the preventive measures it plans to implement in the future to ensure the continuous and reliable availability of oxygen. This includes steps to ensure that adequate backup systems for all critical medical supplies and equipment are in place, operational, and fully functional at all times. These measures are critical to guaranteeing that the hospital is better prepared to handle emergencies and provide uninterrupted care to its patients.
Through this inquiry, the Commission on Administrative Justice aims to address serious concerns about patient safety, emergency preparedness, and institutional accountability. The findings from this investigation are expected to offer clarity on the tragic events and provide actionable recommendations to prevent similar occurrences in the future, improving overall patient care and hospital operations.
