Representative image: Medical workers in PPE look at the reports of a patient suffering from COVID-19 at a hospital in New Delhi, May 2020. Photo: Reuters/Danish Siddiqui.
Bengaluru: In the last two months, Aaditya*, a resident of a district near Bhopal, Madhya Pradesh, has discovered just how hard it is to get information about the last few days of his father’s life, which were spent being treated for COVID-19 in the Hamidia Hospital in Bhopal.
Despite multiple requests, the hospital – run by the Madhya Pradesh government – refused to give Aaditya any medical records for many weeks. These records include the medical certificate of cause of death (MCCD), a.k.a. the cause-of-death certificate. It specifies what disease or accident a person died of.
In fact, only after The Wire Science sent questions to Nishant Warwade, the commissioner at Madhya Pradesh’s directorate of medical education, under whose purview Hamidia Hospital lies, did the hospital share the certificate with Aaditya this week. But many other families continue to wait for similar documents, with no assurances in sight.
Hamidia Hospital has been reluctant to part with these papers even though the families are legally entitled to them. Under the Registration of Births and Deaths (RBD) Act 1969, and Madhya Pradesh’s Registration of Births and Deaths Rules 1999, which draw their power from the RBD Act, all large public hospitals in Madhya Pradesh must fill out the MCCD whenever a person dies on their premises and submit it to the registrar of births and deaths in their district, according to Prema Khakha, joint-director at the Directorate of Economics and Statistics, Madhya Pradesh.
Khakha was responding to questions on behalf of the state’s chief registrar of birth and deaths, R.S. Rathore, whose office compiles all MCCD data collected from district registrars. Further, the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations 2002 state that if a patient’s family requests any medical record, the doctor must give it within 72 hours.
And this applies to MCCDs too, according to S.V. Joga Rao, a healthcare law researcher at Legalexcel, a law firm in Bengaluru. “In the event of a person’s death, unless the cause of death has not been ascertained or was unascertainable, the deceased patient’s attendees are entitled to get a certified and authentic copy of the cause-of-death certificate,” Rao said. “If the hospital is not giving it, all of us need to know why.”
Excuses and abuses
Aaditya’s experience has been particularly Kafkaesque. He wanted a copy of his father’s MCCD because his father’s employer, the State Bank of India, was compensating all families of employees who had succumbed to COVID-19. But to collect this money, Aaditya had to submit proof that his father died of the disease.
After four trips from his home to Hamidia Hospital, over 60 km away, Aaditya said, officials from the hospital gave him only absurd excuses and abuse instead of the MCCD. “They accused me of hounding them just to make some money. I asked them – if you were to collect insurance money, wouldn’t you do the same?”
The first time hospital officials refused him, soon after his father’s death on August 31, Aaditya asked for a copy of his father’s medical reports and test results instead. But one official from the hospital’s medical records department told him this wasn’t possible because the reports were contaminated by the SARS-CoV-2 virus.
“So I told them I would buy my own PPE and fetch the records myself,” Aaditya recalled. “But they didn’t agree to that either.”
Exhausted, he went back to the bank and requested them for a letter explaining why the certificate was necessary. He then took it to Bhopal, hoping the hospital would yield. But the hospital officials turned him down again. “They asked me: if tomorrow, your bank says it wants Alia Bhat’s signature, you think we will give it to you?”
The only document Hamidia Hospital was willing to share was a counterfoil that serves to record that the hospital filled the MCCD. Normally, hospitals give patient families this counterfoil while also submitting the MCCD to the local registrar of births and deaths, an authority appointed by the state under the RBD Act. Families then submit the counterfoil to the registrar to get a copy of the death certificate, and the MCCD if they wish.
The death certificate has general death-related information, such as name, age of deceased, address, etc. The MCCD specifies the cause and sequence of events that led to the death in some detail.
The counterfoil is not the same as the MCCD because it only has space for the name of the person who died and when.
However, an official from Hamidia Hospital’s medical records department, Ajay Jain, had scribbled the cause of death on the counterfoil and signed his name on it – and insisted that Aaditya use this document to claim the compensation.
Aaditya is not the only person who has had to run from pillar to post to get hold of documents to which he is entitled. The Wire Science spoke to three others whose relatives had been treated at Hamidia, but were struggling to access their medical records.
Data obtained by The Wire Science from the Bhopal’s district registrar of births and deaths shows that this is a longstanding problem. It seems that apart from refusing MCCDs to patients, the hospital hasn’t been submitting them to the district registrar either. Of the 1,508 deaths the hospital registered between January and October 2020, it has submitted MCCDs for only 41 (2.7%). In 2018, these numbers were 1,831 and 35 (1.9%); in 2019, 2,038 and 258 (12.6%).
A deeper problem
When The Wire Science asked Hamidia’s Jain as to why the hospital has been neglecting cause-certification, he said it was because no patient family requested the document prior to the pandemic. “But now that so many people have requested them, we will start issuing them,” he said.
At first, the hospital’s medical superintendent, I.D. Chourasia, said he was a neurosurgeon and unaware of the daily workings of the medical records department. But after The Wire Science sent its questions to Nishant Warwade, the state’s commissioner of medical education, Chourasia said that Warwade had asked him to look into the matter, and that the hospital would start issuing MCCDs. Warwade also said he hadn’t been aware of the issue until then.
Lax record-keeping is significant because the 800-bed Hamidia Hospital, established in the early 20th century, is among the oldest and largest in Bhopal, and treats numerous patients from around the state capital. It is also significant that Hamidia Hospital is attached to Bhopal’s Gandhi Medical College. Most Indian states have encouraged medical-college hospitals to implement cause-of-death certification before asking other smaller hospitals to do so – because medical colleges typically have senior doctors who understand the nuances of cause-certification.
So one would expect such an institution not to slip-up on this count, Harleen Kaur, a health law researcher at the National Institute of Public Finance and Policy, New Delhi, told The Wire Science. “It surprises me. One hopes that there would have been a system of sharing MCCDs with patients in a hospital as old as this.”
MCCDs matter for more reasons than life-insurance claims. These documents help map the disease burden in the country, enable epidemiological research and help policymakers better target public-health funds. Every year, the Registrar General of India publishes trends gleaned from these certificates, such as a list of the top causes of death in India. Cause certification can also help track the true burden of COVID-19 in India, which many experts believe is being underestimated.
But for its importance, hospitals often do a poor job of certification or skip it entirely. Several studies have found that doctors don’t fill MCCDs properly. Common mistakes include confusing the mode of death, such as respiratory failure, with the cause of death, such as COVID-19. And even so, according to a report by the Registrar General, doctors wrote up these certificates for only 21.1% of all deaths registered in India in 2018.
Madhya Pradesh had a particularly poor record that year, with its doctors certifying only 10.5% of registered deaths – a figure higher than that of only Jharkhand and Uttar Pradesh. This is in spite of the state requiring all major hospitals with in-patient facilities to issue MCCDs under its Registration of Births and Deaths Rules 1999.
Khakha told The Wire Science that 550 hospitals in the state had been reporting causes of death in 2020; she didn’t know the total number of hospitals with inpatient facilities here that were mandated to report MCCDs, however. But according to a 2018 report on cause-certification from the Registrar General of India, Madhya Pradesh had 5,685 hospitals that year. In Bhopal, out of 156 hospitals, 46 had filed MCCDs, Khakha said.
She said she didn’t know why so few hospitals were reporting. “It is the duty of hospitals to report, and we keep reminding them continuously.”
K.K. Gupta, a joint director in the state department of planning, economics and statistics, said MCCDs simply weren’t a priority for many hospitals. And so far, the registrar’s office hasn’t taken any punitive action. (In any case, under the RBD law, only a fine of Rs 50 can be imposed on an offending medical practitioner, Kaur pointed out.)
An information black-hole
The failure of one of Bhopal’s oldest public hospitals to report causes of death might have remained hidden if not for the efforts of health activist Rachna Dhingra. Soon after the COVID-19 epidemic hit the city, Dhingra, a member of a voluntary group called Bhopal Group for Information and Action, forged a collaboration between her group and the Bhopal School of Social Sciences to set up a helpline for the families of COVID-19 patients at Hamidia.
Through this helpline, she counselled family members to request all documents that they were entitled to receive. But collecting these documents proved very stressful.
According to her, she asked families to seek these documents because they were feeling anxious and cut-off from their loved ones. Across India, many hospitals, including Hamidia, don’t allow patients to meet their COVID-afflicted relatives to prevent the spread of the virus.
But at Hamidia, families were also not receiving copies of medical reports after their relatives had died. “COVID-19 is very different from other illnesses. You don’t see your relatives when they are sick. You see them only after they die, or if they are discharged,” Dhingra said.
This enforced isolation heightened distrust for hospitals. “Families wanted some information in writing. They wanted their medical papers, they wanted a piece of paper explaining what their relatives died of.” Media reports also highlighted that many of those who had died of COVID-19 weren’t being included in the state’s death toll from the disease, making families even more suspicious.
To help them deal with this information lacuna, Dhingra’s helpline asked them to collect all medical records they were entitled to, including MCCDs. However, some of them came back to her saying hospital officials were pushing them away. When Dhingra approached the Hamidia Hospital’s medical records department for a clarification, she was told that the hospital had no practice of issuing such certificates to patients.
According to Joga Rao, awareness about cause-of-death certificates is typically low among laypersons. “Normally, a death summary issued by a hospital is more than enough to perform the cremation,” he said. “So many patient families never feel the need for a cause-of-death certificate. They realise only when they need to make insurance claims or provident-fund claims, etc.”
‘No idea what happened’
Even though Aaditya finally received his MCCD this week – but still not a copy of his father’s medical reports – other families continue to wait.
Among them is Prakash Chandra Sharma, a 61-year-old who works with Madhya Pradesh’s agriculture department in Shajapur district.
Prakash’s father, Kishori Lal Sharma, succumbed to COVID-19 in Hamidia Hospital on September 16, after having been hospitalised in a COVID-19 ward for over a week. In this time, Prakash couldn’t meet his father or even talk to him on the phone, because Kishori Lal was wearing an oxygen mask the whole time.
Sometimes, Prakash said, a helpful hospital worker would send him a photo of his father on WhatsApp to let him know that he was okay. “We would just stand outside the hospital waiting for some news. What could we do? It was the hospital protocol,” Prakash said.
When his father died, Prakash and his relatives were asked to cremate the body in line with the special precautions – which meant maintaining a distance and not touching the body.
The experience left Prakash with many nagging questions, given how chaotic things seemed at the hospital. “We want to know what treatment they gave my father during those days. God knows what they did – did they change his clothes during this time? Did they feed him properly?”
Then, after using the helpline Dhingra helped set up, Prakash requested officials at Hamidia for his father’s MCCD and other reports. But, he said, the hospital gave him nothing except the counterfoil that Aaditya also received. In fact, Prakash has not even received a death certificate yet – which is different from the MCCD but is also mandatory. This is because the hospital needed an identity proof for Kishori Lal to register his death, and which the family didn’t have then.
Sometime this week, Prakash’s brother will make a two-and-half-hour journey to Bhopal with his father’s voter ID to get the death certificate. They don’t know if they will get the MCCD and medical reports, which they also want. “It’s been a very strange experience,” Prakash said. “We are just facing one problem after another.”
Priyanka Pulla is a science writer.
The reporting for this article was supported by a grant from the Thakur Family Foundation. The foundation did not exercise any editorial control over the contents of the article.
* Name changed to protect identity.