The Importance of Strengthening Healthcare Systems: Lessons not learnt

1. INTRODUCTION

"The good physician treats the disease; the great physician treats the patient who has the disease." — William Osler

In the healthcare world, trust plays a huge role. However, there have been cases where individuals pretended to be doctors and carried out serious medical procedures without the right qualifications. Sadly, these actions have led to the loss of lives. Such incidents show that some hospitals may not be doing proper background checks. This highlights how important it is for medical institutions to carefully verify the identity and skills of the people they allow to treat patients. Source info here

2. WHAT HAPPENDED?

Between January and February 2025, a man falsely claimed to be a qualified heart specialist trained abroad. He used fake documents and even changed his appearance to match a well-known medical identity. Using this false profile, he performed over 15 heart-related procedures, including angioplasties and angiographies, at a local hospital.

Tragically, seven patients died after undergoing these treatments. Concerned family members began questioning the doctor’s credentials, which led to an investigation. Authorities later discovered that the individual had no real medical qualification and had faked his entire background.

Even more concerning, the hospital did not report the deaths properly, allowed the release of bodies without proper post-mortems, and reportedly charged families for treatments that should have been covered by a public health insurance plan.

3. UNDERLYING ISSUES 

The case highlights a range of systemic and operational failures that allowed this fraud to go undetected:

Lack of Background Verification Procedures:

There were no formal processes to verify the legitimacy of the doctor’s qualifications or experience through medical boards or international regulatory bodies.

Weak Internal Controls in Hospital Operations:

The hospital lacked a standardized protocol for recruiting and vetting medical professionals and did not establish clinical oversight mechanisms.

Poor Reporting Culture:

Despite patient deaths, the hospital chose not to report the incidents to authorities, undermining transparency, and accountability.

Gaps in Government Monitoring and Licensing:

There was insufficient government oversight into hospital hiring practices, and no red flags were triggered by the sudden rise in surgical deaths.

No Use of Technology for Credential Validation:

In a digital era, the hospital relied on paper documents, making it easier to falsify credentials without verification via online medical registries.

4. IMPACT & CORRECTIVE ACTION

This horrifying incident has had far-reaching consequences:

•        Loss of lives due to negligence and fraudulent practices.

•        Public distrust in private and missionary healthcare facilities.

•        Government investigation into the misuse of public healthcare funds.

It has also prompted discussions on the urgent need for policy-level interventions to prevent such malpractice.

To ensure such tragedies are never repeated, the following corrective actions are recommended:

1.     Mandatory Credential Verification: All hospitals must verify doctors’ degrees, licenses, and references through authorized medical councils and international verification services for foreign-qualified professionals.

2.     Strict Government Audits and Surveillance: Periodic inspections should be conducted by state health departments and NHRC to monitor not just infrastructure, but also patient records, mortality rates, and staff credentials.

3.     Post-Mortem Mandates for Unnatural Deaths: A mandatory autopsy should be conducted for all hospital deaths following surgeries or high-risk procedures to rule out malpractice.

4.     Digital Doctor Registry: Introduce a centralized digital registry for all practicing doctors in India, accessible by hospitals, authorities, and the public.

5.     Whistleblower Protection and Reporting System: A transparent reporting mechanism must be established, where patients and hospital staff can raise concerns without fear of retaliation.

6.     Legal Accountability and Penal Action: Strict legal action should be taken against both fraudulent individuals and institutions that enable or overlook such malpractice.

5.     LESSONS NOT LEARNT:

The doctor was caught a few times earlier as well for impersonation. If suitable action was taken the first time, this wouldn't have been repeated.

Despite earlier incidents of medical malpractice in the country, critical lessons remain ignored:

Over-reliance on Institutional Reputation: Patients often assume that hospitals ensure doctor credibility, when in reality, even reputed institutions can have major lapses.

Lack of Whistleblower Empowerment: Previous cases have shown that staff members hesitate to raise concerns due to fear of job loss. This culture has still not changed widely.

Inadequate Use of Existing Technology: Tools and platforms to verify credentials exist but are underutilized, with hospitals relying on outdated, manual verification processes.

Complacency in Policy Enforcement: Many regulatory guidelines exist on paper, but enforcement is lax, and penalties for violations are not consistently applied.

Neglect of Patient Awareness: Patients are rarely educated on their rights to verify a doctor’s credentials or seek a second opinion, putting them in a vulnerable position.

6. CONCLUSION

This incident shows how serious problems in the system can lead to tragic outcomes. It highlights the need for better checks, stronger rules, and more safety for patients. The loss of lives happened because proper care and oversight were missing, and we can’t let this happen again. It’s time for healthcare to make important changes, focus on quality, and rebuild trust with the public.

How Gorisco Can Help:

We are committed to supporting organizations in developing strong frameworks for both Quality Management Systems (QMS) and Information Security Management Systems (ISMS). These frameworks ensure operational excellence, regulatory compliance, and data security, addressing critical gaps that can lead to issues like those seen in unfortunate incidents.

Our Support Includes:

Credential Verification Frameworks: Implementing structured procedures for verifying the qualifications and credentials of professionals.

Process Standardization: Establishing documented protocols for critical organizational processes, ensuring consistency and efficiency.

Internal Audits & Compliance Checks: Conducting regular audits to ensure compliance with both administrative and operational standards, identifying potential risks early.

Incident Reporting Mechanisms: Enabling real-time reporting of incidents, complaints, or anomalies to drive timely corrective actions.

Corrective and Preventive Actions (CAPA): Implementing systems to identify root causes of failures and ensuring that corrective actions are taken to prevent recurrence.

Continuous Improvement Programs: Promoting a culture of learning, accountability, and ongoing improvement across all departments.

Information Security Management (ISMS): Protecting sensitive data by implementing robust security measures in compliance with ISO/IEC 27001, ensuring confidentiality, integrity, and availability of information.

Partner with Gorisco to design and implement a QMS that upholds the highest standards of care, builds public trust, and ensures compliance with ISO 9001:2015 and other healthcare quality benchmarks.

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