The Justice Kochhar committee, which probed the death of a patient allegedly due to tainted IV fluids, pointed out that the contamination was manmade, and added it was ``deliberate negligence'' on the part of the supplier, testing laboratory and hospital staff for ``personal pecuniary benefit''.

The committee had indicted several top officials of the Union Health and Family Welfare Ministry, the Directorate General of Health Services (DGHS) and the then medical superintendent of Safdarjung Hospital, Dr P.C. Rai, in the scandal.

Tainted IV fluids reportedly left at least 16 patients seriously ill and one dead at the hospital in September 1992.

The episode was brought to light by inquiry reports prepared separately by a DGHS official, the then additional health secretary and the CBI. But these reports were allegedly ignored by the government. According to the three inquiry reports: During 1991-92, Safdarjung Hospital paid more than double the market rates -- (Rs 20 or more per bottle) for IV fluids manufactured by Shree Krishna Keshav Laboratories Ahmedabad -- to Super Bazar for 3,10,000 bottles it purchased over nine months. The hospital had cited an emergency or ``non-availability from other sources''.

The mandatory laboratory tests for the bottles of IV fluids were conducted by Naraina-based Standard Analytical Laboratory. The committee observes that the Health Ministry, in a letter dated June 15, 1992, had advised various hospitals to procure IV fluids manufactured from one of the four concerns it specified only through the Medical Stores Department (MSD). The purchases, it added, were to be made on the basis of competitive price bidding.

The committee notes: ``To a great extent Dr P.C. Rai tried to give evasive replies to the questions put to him by the committee.''

However the committee's report records these extracts from Dr Rai's answers: ``I do not remember whether we made attempts to purchase the IV fluids from either of the four manufacturers mentioned in the circular''. When asked if that meant no such attempts were made, Dr Rai replied: ``I do not remember and as such I cannot say anything''. The panel observes: ``...the MSD on two occasions supplied IV fluids in plastic bottles to Safdarjung but they were not accepted on the ground that they were not in glass bottles''.

Consequently, the report says, the MSD ``brought it pointedly to the notice of Dr P.C. Rai that non-acceptance of supply twice of IV fluids in polypacks was violative of the government instructions contained in circular letter dated June 15, 1992 and that under the circumstances this depot is constrained to withhold supplies to your hospital till acceptance for the item...is confirmed by you''. Justice Kochhar thus concluded that Dr P.C. Rai had violated the government instructions issued from to time in the matter of the purchase of the IV fluids. According to government guidelines, ``...IV fluid products which are supplied in plastic bottles should be preferred over glass bottles...''