Report Analysis

Lentin Commission Report on the Glycerol Tragedy at the

J.J. Hospital, Bombay (Lentin Commission Report)
Submitted by:

Sohel Alam

BBALLB 7th Semester (2020)

CMR University, School of Legal Studies

Submitted to:

Prof. Chanjana Elsa Philip

CMR University, School of Legal Studies

Date of Submission: 27.11.2020

Introduction:

The Lentin commission was formed to inquire into the tragedy of deaths in JJ Hospital. It all
started with the death of Bapu Thambore on 21st January 1986 which was followed by the death
of 13 more people, these people were the patients in the JJ hospital. They all died untimely and
an unnatural death. It was found out that a common drug used by the hospital to combat the brain
swelling and odema was glycerol, this drug was used for these 14 patients, however, this drug
was not any common drug which was used to combat the swelling of the brain but it was dilated
with diethylene glycol which turned out be lethal and was termed as a deadly poison. The entire
report portrays the wrong judgement, the misuse of power by the upper authorities, corruption
and lack of accountability.

Analysis of the Report:

The departments that were concerned in this inquiry were the Neurology, Neurosurgery,
Nephrology and Ophthalmology, Nephrology, Pathology and Pharmacology Departments. The
report records down the accounts of the patients and it was discovered that the patients had
passed on following 4-5 days of burning-through the widened glycerol drug. Heaving,
gastrointestinal dying, stomach torment, guarding and inflexibility, distension and the runs
shaped the early highlights.

Alongside the exposing of absence of responsibility and the absence of correspondence inside
the clinic divisions, the commission report uncovered the gross carelessness of the top
organization in pulling out the executioner drug, as the emergency clinic kept on utilizing the
medication even after not many of the emergency clinic specialists had given a red caution in
utilizing the medication. The commission report gave a comprehension on the medication buy
strategy as open clinics keep the cycle mysterious and it isn't known to many. The JJ Hospital
misfortune occurred on the grounds that the FDA (Food and Drug Administration) conceded an
unlawful permit to Alpana Pharma, provider of the executioner drug glycerol, without ensuring
that essential standards and guidelines had been conformed to.The absence of checks and
balances to ensure that quality drugs reached the public was revealed with clarity during the
commission’s investigations. As these harmful drugs were granted licenses to few high end
pharmacies and further these drugs were given to patients which ultimately would lead to the
deaths of the patients. An issue intensely debated at that point of the commission was that, was
whether or not public hospitals and the drug manufacturers must install an in-house drug- trying
out laboratories to ensure drug purity. Although an obligatory precondition for issuing of a drug
production license, the FDA did no longer insist on its implementation.

The commission had reached the conclusion that the public health system had been reduced to a
capital market for profit making, where human life was of least concern. This and many other
incidents exposed by means of the commission’s report how the buying and licensing of drug has
become vulnerable to the public as there is no means of clarity and accountability from the
hospital’s side. The Lentin report also strongly indicated that the then health minister Bhai
Sawant who was charged with gross ministerial interference, favoritism for extraneous concerns,
and misuse of power and corruption were drawn against him. It encouraged an Anti-Corruption
Bureau investigation on him. The commission pointed out that the politicians turned in on the
public and utilized through these ways to extort money from the medical industry to inflate their
of personal trusts.

Recommendations:

The Lentin report recommended that the administration of JJ Hospital needs to be improved in
order to serve the purpose of saving people’s lives. The commission report also states that
serious actions must be taken against those who have contributed in such crime which lead to
death of 14 patients. The report stated that there should be two deans appointed, one to look after
the medical practice and the other to look after the administration of the hospital. A reasonable
tenure must be assured to the Deans so as to ensure their involvement and commitment to the
institution.

As for the FDA, Justice Lentin emphasized that it was genuinely vital that the provisions of the
Act and Rules be followed and applied by the FDA officials without fear or unwanted favor. The
FDA must be headed by an assertive Commissioner of verified administrative capability,
preferably drawn from the Indian Administrative Service, Indian Police Service or the Defence
Services, capable of withstanding ministerial, bureaucratic and political pressure without
compromising on concepts or being subservient to all of us in the discharge of his obligations or
so that it will live on. He also advocated periodic refresher publications for FDA. Officials to
preserve themselves completely familiar with the provisions of the Act and Rules.

Observation and conclusion:

The commission report clarified and uncovered different pieces of middle class violations in the
clinical calling. The whole structure of FDA had been eroded by widespread defilement,
indiscipline, bias, nepotism and gross ecclesiastical obstruction and there was no finished
responsibility. The wellbeing pastors had infrequently indicated any interest while in force and
authority of the FDA. Truth be told, it was discovered that the wellbeing priest had empowered
defilement and intentional infringement of rules. There were no endeavors made to improve the
working and picture of FDA nor did they attempt to preclude defilement inside.

The discoveries of the Lentin Commission are vital for Maharashtra's general wellbeing as well
as for various states, as most of the medications created in India are produced in Maharashtra and
numerous patients from the US come here for tertiary cure. The commission also listed out that
there is a lot of distance from regulating and implementing requirements on the drug enterprise,
the FDA had willfully allowed substandard medicines to be bought within the marketplace. It is
observed that in spite of crafted by the Lentin Commission and various reports of different
boards, nothing has changed. The nexus of defilement and carelessness in our medical care
gadget is solid anyway is infrequently uncovered without a cautious media, vigorous public
weight, and government commitment.