On the night of August 11, news trickled out of Gorakhpur that 30 children had died in 48 hours after liquid oxygen supply to a hospital had run out. The news sparked outrage across India. But in the dimly-lit wards of Baba Raghav Das Medical College and Hospital, where parents watched over their children anxiously, it made little difference.

Past midnight, around 1.30 am, Srikrishna Gupta’s four-year-old baby began to fade. Nurses handed him a self-inflating bag – or ambu bag – to pump air into the infant. A resident of Bilawa village in Gorakhpur district, Gupta runs a medical store. He had brought his son in that morning after a private doctor, seeing that the baby had breathing trouble, had referred the family to the hospital, which is the only large state-government run facility in the region. Gupta’s baby was placed on a bed with three other infants in the crowded neonatal ward. The doctors did not bother to tell the father what was ailing the newborn.

When the baby’s condition deteriorated, Gupta was asked to manually resuscitate him. “They told me that a ventilator is not available,” said Gupta. Four hours of frantic pumping could not save the baby. He died around 5.30 am on August 12.

In a statement released the previous night, the hospital said the supply of piped liquid oxygen had been disrupted around 7.30 pm on August 10. As soon as the supply ran out, 52 cylinders kept in reserve had been pressed into service. The state health minister Siddharth Nath Singh later claimed that barring two hours on the night of August 10, when the cylinders ran out, there was adequate supply of oxygen in the wards. Singh repeatedly denied the deaths were on account of shortage of oxygen.

But those who lost their babies are convinced the lack of oxygen proved fatal. They say oxygen supply had begun to run low as early as August 7. Brahmadev Yadav of Bagagda village in Gorakhpur district brought his four-day-old twins to the hospital on August 7, after one came down with fever. “The red lights showing low levels of oxygen kept coming on, and then the machine would stop,” said Brahmadev. “Just like the phone when the charger is not properly connected.” One of the twins died on the night of August 9, the other the next morning.

Brahmadev Yadav, whose twin children died at Baba Raghav Das Medical College, Gorakhpur. (Photo: Menaka Rao)

Zahid Khan’s five-year-old daughter Khushi had high fever and was admitted in the Intensive Care Unit late on the night of August 10. He claims she was kept on oxygen from 2 am to 6 am. “Around 6 am, the nurse told me that the oxygen supply has stopped and gave me an ambu bag to pump air,” he said. The resident of Gorakhpur did so for four to five hours. “My hands got tired pumping, but I did not stop,” he said. Two of his relatives helped him. But the child died around 5.30 pm.

Dr Yogesh Jain, a senior pediatrician from Jan Swasthya Sahyog in Bilaspur, Chhattisgarh, said self-inflating bags are not a replacement for oxygen. “An ambu bag draws air from the atmosphere,” he said. “It can be a replacement for the ventilator for some time, but certainly not a replacement for oxygen.” A ventilator helps patients with lowered breathing capacity by blowing air into their airways through a breathing tube. Modern ventilators have a vent for oxygen supply, but are not always connected to oxygen.

More than 60 children died over the five days between August 7 and August 11. Twenty-three children, including 14 babies, died on August 10.

Recalling the spate of deaths, Ishrat Ahmed, whose four-day-old son is still being treated in the neonatal intensive care unit, said: “The entire corridor was filled with cries. Many children died that night. We were all scared.”

Despite the deaths getting national attention, the liquid oxygen supply to the hospital was restored only on the morning of August 13.

The paediatric ICU at Baba Raghav Das Medical College, Gorakhpur on August 14. (Photo: Menaka Rao)

Switching between wards

Located on a sprawling campus in Gorakhpur, Baba Raghav Das Medical College and Hospital spills over with patients, not just from the city and nearby villages, but also from the rest of eastern Uttar Pradesh, neighbouring Bihar and even Nepal. As a tertiary care facility, the hospital is the last resort for critically ill patients and those who have failed to get diagnosed and treated successfully at government health centres and smaller private hospitals. The hospital has three intensive care units – a pediatric unit for children, a neonatal unit for newborn babies and another one for older patients. All three require an uninterrupted supply of oxygen.

Every monsoon, the hospital is flooded with children with the tell-tale signs of encephalitis – high fever and brain inflammation. The paediatric ward has 60 beds. On the first floor of the two-storeyed building is a separate section for encephalitis care, with a 54-bed paediatric ICU and a 40-bed neonatal ICU. All critical cases – not just children suffering from encephalitis – are admitted here.

Parents are not allowed to enter the intensive care units. They stand outside, peering through glass to see how their children are doing. There are two adjoining rooms for infants who are still waiting for admission into the units, or those who are recovered enough to be considered safe. These rooms are called the “stepdown ward”.

Parents say last week, possibly because of low oxygen supply, some children were taken to the stepdown ward even before they had recovered. Ranjeet Mahato’s daughter was born prematurely on July 29 in Bihar’s Gopalganj district hospital. Since the baby had weak lungs, the hospital immediately sent her to Gorakhpur in an ambulance. On August 11, the baby was moved to the stepdown ward. “They told us that the oxygen levels are low and that we should pump using an ambu bag,” said Mahato. “I pumped for two-three hours, but the condition kept getting worse.” The child was moved back to the ICU, and is still being treated there.

Doctors and nurses in the paediatric department fended off questions about how they managed patient care after the disruption in oxygen supply. All that a doctor was willing to say was that they had reduced the saturation levels of oxygen for some patients. “But that cannot cause deaths,” he added hurriedly.

High security at the Baba Raghav Das Medical College, Gorakhpur. (Photo: Menaka Rao)

The pattern of fatalities

At a press conference on Saturday, the state health minister Siddharth Nath Singh listed the causes of all the deaths that occurred on August 10. These were essentially the medical conditions that the children had suffered from: pneumonia, sepsis, kidney injury, abdominal infections, among others. If the children had simply succumbed to their illnesses, why would there be a sudden spike in the number of deaths on August 10?

This year, the paediatric department, including the neonatal unit, has seen 6,264 admissions and 1,527 deaths in less than eight months. With a larger proportion of seriously ill patients, intensive care units of tertiary hospitals often have a higher numbers of fatalities.

Based on this data, which was released by the state director of medical education to the media in the afternoon of August 12, on an average, seven children have died per day in the department this year.

But, on August 10, the number of deaths shot up to 23 – more than three times the average. Fourteen of these deaths occurred in the neonatal ICU, where the average number of deaths over the course of the year has been four per day.

The spike in deaths on August 10 needs better explanation.

As part of its defence, Uttar Pradesh government has claimed the number of deaths on August 10 is not abnormally high – the state health minister cited an average number of 20 deaths per day in the month of August over the previous four years. Child mortality levels usually rise in the monsoon months. But the average number of deaths in the paediatric department for the first six days of August comes to 10-11 deaths per day – less than half the number of deaths reported on August 10.

More significantly, the data shows that the number of deaths in the paediatric ICU rose in July and August but not in the neonatal ICU. The deaths of 14 newborns on August 10 need to be investigated closely.

Data is till the afternoon of August 12, including patients of accute encephalitis syndrome. (PICU: Paediatric ICU; NICU: Neonatal ICU)

Lack of space, lack of sensitivity

While the oxygen supply has been restored, the other challenges faced by the paediatric department have not gone away. The neonatal ICU has 40 beds, but at any given time, the occupancy is more than 100 children, said a doctor from the hospital.

On August 9, when Ishrat Ahmed brought his four-day old son to the hospital, he was told there was no space for him. Ahmed had come from Sant Kabir Nagar district in Uttar Pradesh after his child was finding it difficult to breathe. “They told me that there are already four children on one bed and there is a risk of infection,” said Ahmed. “But I forced them to admit my child. I had no option.”

Almost all the parents Scroll.in spoke to said that their children occupied beds that already had three more children.

Dr Komal Prasad Kushwaha, a former prinicipal of the medical college, said the paediatric department has always spilled over with sick children. “There are no private neonatal intensive care units in the private sector,” he said. “The patients have no option but to come here. We have no recourse but to admit these children. ”

Since it is funded by the state government, the hospital is meant to provide free treatment and medicines to patients, but relatives complained that they had to purchase syringes, cotton and medicines outside the hospital. Taj Mohammed, whose 7-year old son is admitted in the paediatric ICU with fever and seizures, said he had spent more than Rs 11,000 on his treatment. Anil Kumar, whose four-year old daughter has pneumonia and is admitted to the ICU, said: “Doctors write a parchi [a small note] for everything from cotton to syringes.”

What adds to the anxiety of parents is the lack of information about what their children are suffering from, and whether they are actually recovering. Doctors and nurses do not answer questions, said parents.

Gowardhan Kushwaha brought his six-day-old son to the hospital on August 8. He has not seen him since the time he was admitted in the ICU. Nor has he heard from doctors about his condition. “When I asked if I can have a look at the child, the nurse told me to take the child home and keep looking at him,” he said. Despite the staff’s brusqueness, Kushwaha is grateful – at least his baby is still alive.