"Negligence in following the standard operating procedure (SOP) for holding tubectomy camps and substandard medicines led to the incident," it says.
Chief Minister Raman Singh today tabled the report in Assembly.
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The relatives of seven of the deceased women had submitted affidavits before the commission, apart from social workers, lawyers, NGOs and the government.
The then Block Medical Officer (BMO), Takhatpur; duty in-charge at sterilisation camps, doctors who conducted operations, BMO posted at Community Health Centre, Gaurela, then medical officer CHC Takhatpur, drug company Mahawar Pharma (manufacturer of ciprocin-500 medicines distributed in the camps),were found guilty for the incident, it says.
Technical Lab and Pharma Limited Haridwar (manufacturer of poison-laced ibrufen-400 medicines distributed in the camps), retailer of ciprocin-500 Kavita Pharma Bilaspur, district procurement committee Bilaspur constituted to purchase medicines, then licensing authority which issued license to Mahawar Pharma Pvt Ltd and drug inspector were also held guilty.
The SOP of National Family Welfare Programme was not followed in the sterilisation camps. Directives of the Supreme Court were ignored and even the rules regarding sterilisation of the protected Baiga tribe women were violated, it says.
For future, the commission has made some suggestions which includes organisation of camps only at government hospitals, selection of hospitals by the committee constituted at the state level and construction of a government lab for the examination of medicines in the state.
The one-member commission was headed by retired district and sessions judge Anita Jha.
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