An eight-member expert committee, set up by the Rajasthan government to probe the recent maternal deaths, has flagged several procedural lapses, including poor monitoring of high-risk pregnancies, insufficient medical treatment records and gaps in infection control mechanisms, The Indian Express has learnt.Earlier, the World Health Organisation (WHO) had sought information on the possible link to ineffective oxytocin — an injection used to induce labour and to contract the uterus for preventing blood loss after delivery. The Rajasthan Drug Testing Laboratory had found a batch ineffective, saying tests revealed that the injections contained no trace of oxytocin, its active ingredient.Additionally, the licences of the units of Jackson Laboratories, the manufacturer of oxytocin, in Punjab and Himachal Pradesh were cancelled for non-compliance of a 2023 order to stop production. Sources said the current inspections found widespread irregularities, including the absence of evidence of key tests regarding drug purity, and proof of data fudging.Read | Maternal deaths and a search for answers inside Rajasthan’s second biggest govt healthcare facilityThe Union Health Ministry had sought a detailed report on women developing complications following caesarean operations across several government hospitals in Rajasthan, with some resulting in casualties.Five women died after undergoing caesarean deliveries in Kota in May; seven others had severe complications, some requiring dialysis after suffering kidney failure. This was followed by two more deaths in June, after six women developed kidney failure in Bikaner. Also in June, two women developed complications after undergoing C-sections in Paota, Jodhpur. The Rajasthan authorities have denied a link between the deaths.In its report submitted in June-end, the eight-member panel blamed procedural lapses in managing high-risk pregnancies. “We also note that clinical presentations are different in almost all cases… drugs leading to any reaction or causing shock is negligible. Committee views that absence of active pharmaceutical ingredient oxytocin cannot be attributed mortality,” it said.The report, reviewed by The Indian Express, said the women died of different medical conditions, with no single common cause linking the deaths. Instead, it flagged poor monitoring of high-risk pregnancies, missing treatment records, deficiency in taking informed consent, and poor infection control.Story continues below this ad“There were several factors that led to these deaths and the committee has recommended improving the protocols in the hospitals. While both hospitals (in Kota) do see such deaths as they tend to receive the most complicated cases, unfortunately, the deaths were clustered and therefore got highlighted,” Gayatri Rathore, Rajasthan’s principal health secretary, told The Indian Express.The report, based on review of clinical records of 12 women who died or developed severe complications, also analysed the report of a separate six-member committee from AIIMS.Also Read | Rajasthan maternal deaths: Severe bleeding, sepsis and hypertension may also have played a role, say expertsAccording to the state committee’s report, the AIIMS report raised some “major points of concern” regarding “sterilisation and OT infection control practices, post-operative critical care monitoring deficiencies, pharmacovigilance, drug storage and administration related practices”. “These need to be taken cognizance of and followed up to adhere to protocols,” it said.The state committee noted that the cause of death was different in all cases. According to the report:Story continues below this ad* At J K Lone Hospital in Kota, one woman died due to a pre-existing heart disease, and another due to complications from excessive blood loss in postpartum haemorrhage.* At New Medical College Hospital in Kota, one woman died due to pulmonary embolism caused by disseminated intravascular coagulation, a condition where the body’s clotting mechanism goes into overdrive which led to a clot in the pulmonary artery in this case.* Another woman at the Kota hospital died of hypovolemic shock, a condition in which severe blood loss causes multiple organ failure, including kidney failure.* A third death at the same hospital was due to chorioamnionitis, where a stitch on the cervix to prevent premature birth led to infection of the membranes surrounding the foetus and amniotic fluid.Story continues below this adThe report also flagged lapses in record-keeping at the hospitals, including inadequate notes on the patient’s history, treatment given, monitoring data on parameters like blood pressure and pulse rate. “This is noted not only in clinical case notes but also in operation theatre notes and nursing documentation,” it said. “There is an urgent need to strengthen record-keeping practices,” it said.“An assumption is being made that routine checks were not performed since none of them has been recorded,” said a person privy to the matter.The committee also found that the hospitals were using pre-printed clinical notes and treatment orders. “Such practices are not consistent with accepted standards of individualised patient care,” it noted.It also found deficiencies in the process for getting informed consent. “There is a need to strengthen the consent process to ensure that procedure-specific risks, benefits, alternatives and potential complications are clearly explained and documented,” the report said.Story continues below this adThe committee found these deficiencies were a matter of routine practice in these hospitals. “Certain protocols related to obstetric emergency care, post-operative monitoring, and management of high-risk pregnancies require review,” it said.Based on the findings of the AIIMS committee, which included a microbiology expert, the state committee noted that while there was no evidence to link the deaths to infection acquired in the hospital, there was a need to strengthen infection control practices. The AIIMS committee had flagged gaps in infection control mechanisms.The hospitals also did not have mechanisms to monitor the availability, inventory, and use of various drugs, the state committee said. It underlined the need for SOPs on “procurement, storage, maintenance, dispensing, and monitoring of drugs and consumables”. “In no case there has been any mention of having been given additional oxytocic or uterotonic medications as per clinical records,” it said.“There is also conspicuous absence of protocols for storage and infusion of blood products,” the report said.Story continues below this adDr T Shubhamangala, head of the Rajasthan committee and assistant mission director of Rajasthan’s National Health Mission, did not respond to phone calls.Dr Hrishikesh Pai, former president of the Federation of Obstetric and Gynaecological Societies of India, said: “Unless the deaths can be conclusively linked to faulty oxytocin by a death review committee, we have to assume they happened because of complications of high-risk pregnancies. These numbers are not unlikely for bigger hospitals that usually receive the most complicated cases”.He said an important indicator of whether these deaths were unusual would be a spike in maternal mortality rates. While the New Medical College Hospital in Kota recorded 14 maternal deaths in 2025, there have been three deaths so far this year. J K Lone Hospital in Kota recorded 25 maternal deaths in 2025 and four so far this year.