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The patient at the heart of the MRI scanning and brain surgery controversy that led to neurosurgeon Dr Sonam Jamtsho submitting his resignation passed away on 12th March 2026.
The 70-year-old patient, Chandra Maya Ghalley, underwent a total of six brain surgeries and passed away finally due to a multi-drug resistant organism (MDRO) infection that resulted in acute respiratory distress syndrome and her death.
The patient’s son, who is currently in Gelephu, and just finished with the last rites, consented to use his mother’s name and share her story.
He said that perhaps things may have gone differently if the MRI was provided before the first surgery, as the doctor would have found the exact cause of the stroke or located the exact problem, and moreover, the first surgery was the main surgery lasting four hours.
The son said his mother had blood pressure which kept fluctuating, and she was advised to take medicine, but she did not as it was sometimes high and sometimes low or normal.
What happened on 29th December 2025
He said on the day his mother had taken a bath around 2 pm after which she complained of a severe headache.
His mother was in Thimphu at his sister’s house, and with the headache not subsiding, they took her to the Emergency Room at around 4.40 pm after which a CT scan was done on her brain at around 6.30 pm showing hemorrhage or bleeding.
The son said his mother passed out just before the CT scan, and while undergoing the CT scan, even while unconscious, she threw up in the machine area.
The emergency physician on duty and a surgical resident was initially assessing the patient and they then consulted Dr Sonam Jamtsho who decided that immediate surgery was needed, but that an MRI was needed since the bleed was atypical with suspicion of underlying abnormality.
Dr Sonam had felt an MRI was needed to rule out abnormal vasculature as surgical planning without this investigation carries a high risk of catastrophic outcome.
The emergency physician contacted the radiologist doctor on duty asking for an MRI, but was refused as the radiologist felt the CT scan was enough and that ‘urgent MRI is not done after 3 pm’ as stated in the incident report by Dr Sonam. He said in the report that the patient could not wait until morning as any delay would significantly worsen her functional outcome and chances of survival.
With the radiologist being adamant on not doing the MRI, the patient was taken for surgery at 10.30 pm after the family was told the risk of mortality exceeded 50 percent, and consent was sought. Dr Sonam also shared the name of the radiologist with the family if they wanted to purse any medico-legal case.
The patient had been intubated for ventilation.
After a four hour surgery, Dr Sonam said it was a success as the abnormal vessels could be identified and managed intraoperatively.
More surgeries needed
The son said after the surgery, Dr Sonam had advised the patient be taken to the Intensive Care Unit (ICU), but his mother was taken to and kept in the surgical ward for three days as there was no bed available in the ICU.
The son said that after the fifth day of the surgery, Dr Sonam mentioned that a CT scan showed some left over blood or fluid in the brain, and so she underwent another surgery where a part of her skull was removed to lessen the pressure on the brain.
Surgery was again done two more times on his mother through January and February which meant a total of four surgeries.
The son said that after his mother became unconscious before the CT scan on 29th December 2025, she never opened her eyes again and was essentially in a comatose state throughout and intubated.
Gelephu and back
With the family residing in Gelephu, they had asked if it was possible to transfer the patient to the Gelephu Regional Referral Hospital, and the doctor agreed as he felt the patient’s condition had stabilized and was in fact improving. The patient was transferred to Gelephu via an ambulance on 10th February 2026.
The son said he mother was kept in the Gelephu Hospital for around a week, but her condition worsened and she had to be brought back to JDWNRH.
In JDWNRH, it was diagnosed that she had a MDRO infection and she was kept in an MDRO isolation unit. It could not be determined if she picked up the infection in JDWNRH or in the Gelephu Hospital.
The son said his mother was operated on two more times, but she could not recover and ultimately, she passed away on the afternoon of 12th March 2026.
The son said, “I already lost my mother and my only prayer is such lapses in major cases like my mother should not happen to other patients. I am grateful to Dr Sonam who revoked his resignation.”
Medical opinion
A medical doctor from JDWNRH, who requested anonymity and is familiar with the case, said that not conducting the MRI did not impact the outcome, as the first surgery was successful. The doctor added that the death ultimately occurred due to an acquired multidrug-resistant organism infection, which can happen during prolonged hospital stays.
The doctor said that in brain surgery cases, outcomes can vary widely, with some patients remaining in hospital for up to nine months before eventually walking home. In many cases, due to stroke-related damage, patients may experience lasting effects ranging from loss of speech to impaired movement.
The doctor added that, given the slight improvement in the patient’s condition, transfer to Gelephu had been permitted and physiotherapy had in fact been recommended.
Meanwhile, another source from JDWNRH said that two other doctors later agreed with the radiologist that an MRI was not essential.
Systemic improvement in JDWNRH
The next question is what systemic improvements will be made at JDWNRH to ensure that a similar ‘MRI incident’ does not happen again, as what outraged the public was the claim that MRIs are not conducted after office hours.
Here, The Bhutanese spoke to the President of JDWNRH, Dr Pem Namgyal, who said that what happened that night was a communication issue.
He said MRIs happen after office hours, and in 2025 there were 80 MRI scans done after regular hours, and in 2026, 44 MRIs were done beyond regular hours.
In his incident report, Dr Sonam cited a letter dated 23rd December 2025 where clause 4 states that during emergency hours, decisions on imaging requests shall be made by the emergency physician and the radiologist on duty.
Dr Sonam, in his report, said that both the emergency physician and he wanted the MRI done, but the radiologist refused, citing office hours.
Dr Pem said that MRIs are generally not done after 3:30 pm, but in emergencies they are always made available.
He said the crux of the issue was that the radiologist and Dr Sonam were not communicating directly, but instead were communicating through the emergency physician, and that too through WhatsApp messages.
Dr Pem added that there was a failure on both sides to engage directly, and while the radiologist felt that a CT scan was sufficient to detect the bleeding, Dr Sonam did not call the radiologist to explain why an MRI was needed in addition to the CT scan.
Dr Pem said that either side should have escalated the matter to their heads of departments who would have resolved the issue.
Dr Pem said that JDWNRH has only one MRI machine, which is in constant use and experiences frequent breakdowns. He added that there had been a number of unnecessary scans being ordered, so he introduced a framework requiring that if junior doctors such as residents or GDMOs (MBBS) request an MRI, it must be supported by a consultant or specialist.
The President said he wanted the use of MRI and Colour Doppler machines, which are expensive, to be rationalized.
On the night after everything happened, Dr Sonam had messaged the President to inform him of the refusal of the radiologist and the President replied saying he authorizes the use of MRI.
However, Dr Sonam had messaged to inform about the situation as it was already too late. Dr Pem thought that Dr Sonam was seeking his permission due to the above new rule, which was not the case.
On the way forward, Dr Pem said there is no need to introduce a new Standard Operating Procedure (SOP) as the system already exists. He said that when a request is received, the radiology staff on duty will assess whether the service is needed or can be provided, and if there are disagreements, they should be escalated to their head of department.
“I am going to revisit the SOPs again and re-emphasize that going forward people should not argue among themselves, and do what needs to be done, and if there is differences, escalate it to the HOD and once the HOD asks for action, and there is still no action then there will be administrative and disciplinary measures,” said Dr Pem.
He said this is not just between neurology and radiology departments, but across all departments.
At the end of the day, the key lesson from the incident is that once a patient reaches the ER or hospital, the priority should be to process them as quickly as possible for necessary medical care, so that minimal time is lost.
