For example, a lady who had TB indicators and symptoms was not assessed for that illness. Delays in procedures at the frontline and referral hospitals contributed to 7 out of 30 deaths. For instance, there have been crucial delays in a hysterectomy in managing blood loss; and likewise in a termination of being pregnant the place it appeared that the workers waited for the child to mature to 34 weeks.

A majority, forty one out of 65, who were first admitted to a frontline hospital have been transferred on the same day they arrived. However, 21 out of 65 had been on the frontline hospital for many days earlier than they have been transferred to the height hospital. For example, one lady was transferred after sixteen days on the frontline hospital and died 23 hours after arrival. Two other girls had been at a frontline hospital for 6 and 5 …