The decision to fly the victim of a gang rape that outraged India for treatment in Singapore made little medical sense as the woman was so severely injured that her death was all but inevitable, doctors say.
The government, on the back foot after furious street protests and stinging criticism of authorities over the December 16 rape in the capital, New Delhi, has struggled to defend its decision to send the 23-year-old physiotherapy student overseas. She died 48 hours later.
With a deadly infection seeping into her blood from damage done to her intestines during the assault, complicated by a cardiac arrest and damage to the brain, she was just clinging to life when she was flown 4,000 km from New Delhi to Singapore late on December 26, doctors said.
"It was ethically and morally wrong to have taken her out, given that she was sinking and her chances of survival were next to zero at that stage," said a doctor at New Delhi's All India Institute of Medical Sciences (AIIMS), which was advising the team treating the woman at a sister hospital across the street.
"Such a thing raises false hopes in the minds of the family, the community. No doctor in his right mind would do this, unless you want to get the patient off your back," said the doctor, who declined to be identified, saying colleagues at the government-run hospital who had spoken out had been warned of consequences in what has become a politically explosive case.
The woman, who was assaulted by five men and a teenager on a moving bus after a male companion was beaten unconscious, cannot be named under a law that prohibits identifying victims of rape.
Another doctor who was consulted during the woman's care at New Delhi's Safdarjang hospital, where she was taken following the assault, said she had been getting the best possible treatment in India and the question of why she was shifted should be answered by the government.
Many security officials have said they feared the protests would escalate if the woman had died in New Delhi, but the government has said the only consideration was her wellbeing.
"The idea was to give her the best possible treatment," said Harish Rawat, a government minister who attended a cabinet meeting on the woman's condition and the efforts to save her.
"I don't think the idea was to run away from the problem. Death here or death abroad would still have the same impact," he said. "We felt if there was a chance to save her, it should be tried. Take her to a transplant facility abroad."
At the time of the transfer, authorities at Safdarjang said her condition was critical which was why they decided to move her to Singapore's Mount Elizabeth Hospital, which specialised in multi-organ transplant.
But a transplant for her damaged intestine, if at all possible, was months away, doctors said. At the time of her transfer, the woman, unconscious since a heart attack the previous night, was in no condition to go through such an operation.
"One cannot think about intestinal transplant at this moment," Samiran Nundy, the head of surgical gastroenterology and organ transplantation at the Ganga Ram Hospital in New Delhi, was quoted as saying in newspapers.
"First, the infection spreading in her should be stopped, then one can think about transplant."
Within 40 hours of her arrival in Singapore, doctors called her family and told them the end was near, even as millions prayed at home in the hope that she would pull through.
"Sepsis followed by cardiac arrest is a terminal event in 99 percent of cases," said the doctor at AIIMS, referring to blood infection.
"Doctors will have anecdotal evidence about one or two cases in their whole career of somebody who survived. I had one case, a woman, but she too died within a month. Yes, miracles happen, but you were not looking at one in this case. It was clear to everyone, especially after the cardiac arrest."Protests and panic
Piecing together the events leading up to her death tells a tale of authorities in Delhi trying to defuse public anger over the attack by initially insisting that she was getting the best possible treatment, and then, as things began to go wrong, getting increasingly worried that the protests that tapped a deep vein of frustration, could spin out of control.
The alarm bells for the government rang late on Christmas night when the woman suffered the cardiac arrest. That was nine days after she was brought in to Safdarjang hospital in a life-threatening condition after the brutal assault - she was assessed then as 5 on a scale in which 6 is rated as no chance of survival.
After the heart attack, her pulse rate became critically low. Doctors resuscitated her after three to four minutes but by then she had become unconscious, caused by lack of blood to the brain. She never regained consciousness from that point on.
Equally worrisome, the infection from her injured intestines had seeped into her blood and was spreading to her vital organs.
For the government, shaken by the scale and intensity of the protests that focused on the lack of safety in the capital for women, the deterioration in her health was cause for concern.
Even as the union cabinet met the next morning, arrangements to fly the woman for treatment in Singapore were being put in place.
One official said the public mood was so fragile that the government felt that if she died in India, some people would have blamed the government for not sending her abroad for treatment.
"You can argue this the other way. They would have said 'if Sonia can go abroad, why not this girl'," the official said, referring to the head of the ruling Congress party, Sonia Gandhi, who travels abroad for treatment of an undisclosed condition.
Outside the prime minister's office where the cabinet met, thousands of baton-wielding police including crack members of Rapid Action Force kept the area under a lockdown. Days earlier, pitched battles broke out between hundreds of protesters and police at the scene, in which a policeman was killed.
Protesters had climbed the walls of South and North Block, the high-security seat of government, while others swarmed towards the iron gates of the presidential palace. They carried placards such as "The only two women safe in Delhi are Sonia Gandhi and Sheila Dikshit". Mrs Dikshit is the chief minister, the top elected official of the local government of Delhi.
A government official privy to the handling of the protests said the administration had not anticipated that so many students would come out onto the streets and that the protests would last for so many days.
But when protesters showed up at the presidential palace, the line had been crossed in the security agencies' mind.
"It was a near-breach of security at the presidential palace. The officials tasked with security didn't know how to control the protesters, if they had jumped over its gates. Would you fire at the students, the housewives?" the official asked.
The Intelligence Bureau, which coordinates all domestic intelligence, had been warning that the public mood may turn uglier, the official said.No passports
At Safdarjung on the morning of December 26, a team of doctors arrived from Medanta Medicity, a private medical centre which runs an air ambulance service. Their mandate was to assess whether she could survive the airlift, said Dr Yatin Mehta, head of critical care at Medicity.
"The decision was to take her out of the country. Our job was to determine whether she could take the airlift, not whether she should be going or not," said Dr Mehta, who accompanied the woman on the flight.
He said the option of sending her to Cambridge in Britain to a hospital that specialises in transplants, was considered but dropped because it would have involved a refuelling stop for the aircraft and a two-hour road trip upon landing in London.
Flying her to the Canadian city of Toronto, which also has a specialised organ transplant centre, was also vetoed. They zeroed in on Singapore, six hours flying time away.
It is highly unusual for someone to be flown out of India for critical care. If anything, the traffic is the reverse, with people travelling to the country for treatment.
In the event, the transfer to Singapore was successful, Mehta said, although the woman suffered a drop in blood pressure during the flight. "We were prepared for that. We handed her over to Mount E in the same condition she left the hospital in Delhi," he said, referring to the Singapore hospital.
The woman's family first got wind of the plan to transfer her at hospital in Delhi, when her brother noticed a flurry of activity and a staff member said that doctors were considering moving her.
"We accepted the decision. We were not interfering in the treatment. The doctors said it was in the best interest of our sister, we accepted it. Our only condition was to save her," the brother told Reuters.
Shortly afterwards, officials from the foreign ministry arrived and issued the family travel documents, since none of them had a passport. Their pictures were taken at the hospital.
Three ambulances arrived at the hospital. One of the ambulances headed into the interior of the city and another took the route to the Medanta centre, followed by a convoy of television crews.
A third, carrying the woman, sped away to a special section of Delhi airport, giving everyone the slip.
After she was taken to Singapore, authorities in the city-state's Mount Elizabeth Hospital were frank about her bleak chances for survival.
"The patient is currently struggling against the odds, and fighting for her life," Chief Executive Officer Kelvin Loh said in a statement a day after she was admitted.
"Our medical team's investigations upon her arrival at the hospital yesterday showed that in addition to her prior cardiac arrest, she also had infection of her lungs and abdomen as well as significant brain injury."
Later that day, Mr Soh said her condition was deteriorating.
Her family was told the end was near.
"We didn't expect her to go so quickly," said her brother, who was with her when she died. "At 9:30 p.m., the doctors called us in and said they were sorry, they couldn't do anything more. Her vital organs were failing."
"We went inside and stayed with her the whole night. We saw her heart beat slowing down on the machine. It kept dropping and then dropped to zero. The time was 4:05 a.m."
© Thomson Reuters 2013