The death of a newborn and her mother at the capital's Central Hospital in June occurred primarily due to the duty doctor's failure to assess the patient's condition, and the patient and her husband's insistence about normal delivery instead of a C-section, an investigation by the health ministry has found.

The hospital authorities may also have some "liabilities," said the report, prepared based on the statements taken from everyone engaged in the treatment of Mahbuba Rahman Akhi, 25.

She died on June 18 while in intensive care at another hospital, eight days after the death of her newborn following a last-moment C-section in the early hours of June 10.

"We were tasked with finding out who played what roles, and we did it. Now the ministry will decide about the punishment," Hossain Ali Khandaker, additional secretary (Legal Wing) at the health ministry, told The Daily Star.

The committee submitted the report to the health minister, secretary of the health services division, director general of the health directorate and three other high officials at the health ministry on August 2.

Dr Shahjadi Mustarshida, the duty doctor, and Dr Muna Saha, another physician, were arrested and sent to jail in connection with the incident. They were freed on bail last month.

According to the investigation report, Dr Sangjukta Saha, a consultant at the hospital, uploaded numerous promotional videos on her Facebook page showcasing her skills in assisting normal childbirth at Central Hospital.

Having seen those videos, Mahbuba, who had wanted a normal delivery, consulted Dr Sangjukta and took advice from her twice during her pregnancy.

Mahbuba went into labour around noon on June 9, when she was first taken to Titas Upazila Health Complex in Cumilla. Doctors there recommended a C-section due to complications, but both Mahbuba and her husband Yakub Ali declined to follow their advice, the report said.

Subsequently, the couple spoke with the assistant of Dr Sangjukta Saha and headed for the Central Hospital on assurance that Dr Sangjukta will supervise the delivery.

However, Dr Snjukta Saha left the hospital around 9:30pm on June 9, assigning Dr Shahzadi Mustarshida, who does not have a gynaecology degree, to handle the case, according to the report.  

Dr Snjukta also did not inform the hospital authorities about her absence.

However, until 12:25am of June 10, the attending physicians did not disclose to Mahbuba and her husband that Dr Sanjukta Saha was not around.

Later, Dr Shahzadi Mustarshida and Dr Muna Shaha, who worked as part of Dr Sangjukta's team, performed a C-section, leading to the death of the newborn and the mother, the report said.

The investigation committee pointed out some malpractices by Dr Sangjukta, including making videos on social media about natural childbirth with some exaggeration, telling fellow doctors to treat patients using her name when she was not around, and telling Dr Shahzadi to treat Mahbuba when she was not there.

The committee identified four anomalies of the hospital authorities. They are permitting Dr Sangjukta Saha and Dr Muna Saha to treat patients with expired licences; concealing that Dr Sangjukta Saha was not available at the hospital; allowing other physicians to treat Mahbuba; and taking no action against the illegal campaign on social media by Dr Sangjukta.

The committee said that Yakub Ali, Mahbuba's husband, had some liabilities. The report said that Yakub was insistent about normal delivery until the last moment although Mahbuba was in labour pain for about eight hours.

The committee cleared Dr Farida Akter Mili, Dr Ehsan Jamil, and Dr Sakhawat Alam since they went to the hospital when the patient was already in a critical condition.

Health Minister Zahid Maleque did not respond to our phone calls and text messages last night.

Dr MA Quasem, Vice Chairman of Central Hospital, admitted before the investigation committee that they made a mistake by allowing Dr Sangjukta Saha to treat patients with an expired licence.

Contacted last night, he said, "Checking doctors' licence is not our responsibility alone. It is also the responsibility of Bangladesh Medical and Dental Council."