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Some children had their eardrums pierced so that a drug, not approved for medical use anywhere else in the world, could be applied. Such tests needed approval but the hospital did not apply to the ministry.
In another case, a painful procedure using a needle to draw urine from the bladder for testing was performed without the necessary ministry approval.
Unlicensed drugs and invasive procedures were also used on patients, sometimes by researchers who were not even doctors.
And even though any fatality during such clinical tests should be reported to the ministry within 48 hours, it took researchers more than a week to pass on the information in 21 out of 37 deaths. Some took more than a month.