The Commission on Administrative Justice (Office of the Ombudsman) has invoked its suo moto powers to launch an inquiry into the reported deaths of three patients at Coast General Teaching and Referral Hospital. As part of this investigation, the Commission has written to the hospital’s CEO seeking clarification on several key issues highlighted in recent media reports.
The Commission is requesting a detailed report outlining the full schedule of all planned maintenance activities for the hospital’s oxygen plant, covering the period leading up to and including the date of the alleged oxygen supply disruption.
It also seeks information on the specific procedures that were followed in planning and executing the scheduled maintenance. This includes details of any risk assessments conducted prior to the maintenance work to identify potential impacts on patient care, particularly for those reliant on oxygen.
Further, the hospital is required to clarify whether any alternative or backup oxygen supply systems were in place and operational during the maintenance period. If such systems existed, the Commission demands an explanation as to why they were reportedly insufficient or not effectively utilized.
The Ombudsman also wants a clear outline of the steps the hospital is taking to ensure that patients’ rights to timely and adequate healthcare, including immediate assistance from medical personnel during emergencies, are fully respected and upheld.
Additionally, the Commission is demanding a comprehensive report detailing the hospital’s treatment protocols, internal policies, and enforcement mechanisms. This includes information on the hospital’s policies and procedures for maintaining and backing up critical medical equipment such as oxygen supply systems.
The inquiry also calls for disclosure of the hospital’s internal incident reporting and investigation procedures that were activated following the reported oxygen disruption and subsequent deaths. Specific attention must be given to the actions and responses of medical personnel and maintenance staff who were on duty at the time.
To ensure accountability and avert similar tragedies, the Commission has further requested an action matrix from the hospital. This should include any disciplinary actions being considered against staff involved in the planning or implementation of the maintenance work, or in the response to the disruption.
The hospital must also detail the preventive measures it plans to adopt to avoid a recurrence of such an incident, particularly steps to ensure the continuous and reliable availability of oxygen.
Lastly, the Commission expects the hospital to outline the measures put in place to guarantee adequate backup systems for all critical medical supplies and equipment.
Through this inquiry, the Ombudsman aims to address serious concerns regarding patient safety, emergency preparedness, and institutional accountability. The findings are anticipated to provide clarity on the tragic events and offer actionable recommendations to prevent future occurrences.
