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The following is issued on behalf of the Hospital Authority.
In response to a complaint lodged earlier by family members of the deceased patient Madam CHAN Wun-sik, Princess Margaret Hospital (PMH) had appointed a Special Investigation Panel (the Panel) to investigate the facts and circumstances surrounding this complaint, and to make recommendations, if any, to the Cluster Chief Executive of Kowloon West Cluster (KWC).
Today (23 August), the Panel has submitted the Investigation Report to Dr Lily CHIU, Cluster Chief Executive of KWC and Hospital Chief Executive, PMH. Upon receipt of the Report, PMH has carefully examined the findings and recommendations, and will take positive follow up actions on the recommendations made. The Hospital will accordingly submit a copy of the Investigation Report to Hospital Authority (HA) Head Office for reference.
Dr CHIU expressed her heartfelt gratitude to the three panel members for their hard-work and efforts in assisting the hospital to investigate this complaint case and making the recommendations to her. Dr CHIU expressed that the hospital will consider seriously the Panelˇ¦s recommendations. She hoped that both Madam CHAN Wun-sikˇ¦s relatives and the concerned caregivers would accept the findings of the Report. With regard to the dissatisfaction of the family members of Madam CHAN, Dr CHIU expressed her sincere apology that the hospital had not been able to fully understand the patientˇ¦s needs during her hospitalisation.
Abstract of the Report is as follows:
Complaints and Allegations raised by family members of Madam CHAN Wun-sik
-On 11 July 2007, the ward nurses were unhelpful in assisting the son to book private computerized tomography scan to examine the intra-abdominal and adrenal pathology of Madam CHAN Wun-sik.
-On 19 July 2007, Madam CHAN Wun-sik sustained hip fracture after a fall at her bedside, she was said to have been left unattended for a few hours, and that her fall was found by a ward attendant rather than by the nurses.
-On 21 July 2007, Madam CHAN Wun-sik developed acute deterioration of her respiratory condition. There was delay of the portable X-ray chest investigation, and that this delay contributed to her death.
-From the period of admission on 3 July 2007 to prior to Madam CHAN Wun-sikˇ¦s fall on 19 July 2007, the nursing attitude, nursing observation and attention to Madam CHAN Wun-sik was unsatisfactory.
Summary findings
-The Panel found that ward nurses had, within their available time and resources, made substantial efforts to attend to the booking of private CT scan for Madam CHAN Wun-sik. It was hence not a cost-effective use of nursing time to have nurses call up private hospitals to solicit non-clinical information. The role and procedure should be made explicit to staff and public for having clerical staff rather than nurses to make such calls.
-The Panel was able to ascertain, by crosschecking the attendance sheets of the patient next to Madam CHAN Wun-sik, that nurses had been in and out of the ward cubicle regularly and frequently before Madam CHAN Wun-sik fell. The Panel also ascertained that it was the nurse rather than the Health Care Assistant who first found Madam CHAN Wun-sik sitting on the floor.
-The Panel found the nursing observation of Madam CHAN Wun-sik in the morning of 21 July 2007 to be adequate. On that morning, regular bedside oximetry to check blood oxygen was able to detect oxygen de-saturation in Madam CHAN Wun-sik while she was still fully conscious with normal vital signs. The on-call house officer (HO) and Medical Officer (MO) were informed without delay (HO at 0704 hrs and MO at 0727 hrs respectively). Oxygen flow was stepped up by verbal order of House Officer between 0700ˇV0730 hrs. Madam CHAN Wun-sik was assessed and managed by on-call Medical Officer at 0805 hrs, and then at 0855 hrs by Medical Officer in-charge, who considered the possible diagnosis of pulmonary embolism. The medical care provided was found to be appropriate. The on-call Medical Officer had ordered portable X rays together with a number of blood tests and electrocardiogram. However, Chest X ray is not a useful means to diagnose pulmonary embolism, and would not affect clinical decision or outcome. Nonetheless, on reviewing the arrangements for portable X ray service, the Panel did find room for improvement.
-The Panel heard that individual nurses were under the impression that Madam CHAN Wun-sik was independent in character, and therefore not in the habit of calling for assistance. The Panel had reason to believe that Madam CHAN Wun-sik did have perception that such call for personal assistance would be unwelcome. The Panel noted that ward nurses and ward manager were unaware of such negative feeling. Although the ward had implemented cubicle nursing as model of patient care, the nurses appeared not been able to establish rapport or trust with the patient and relatives in a continuous manner. It was noted that towards the later part of the hospitalization, different nurses were assigned in turn to care for Madam CHAN Wun-sik. This might be due to reasons as staffˇ¦s sick leave / vacation leave / or other duty assignment considerations. In this case, inadequate communication between the patient / relatives with nursing staff had led to strong resentment from the relatives.
Panel Recommendations
-On booking CT scan at private hospitals, the Panel considers that the existing practice of nurses booking CT scan at private hospitals need to be reviewed.
-The Panel suggests that the information file for private CT scan booking should be improved, to include explicit instructions to staff and user-friendly information leaflet for patients and their relatives.
-On fall prevention, the Panel considers the provision of bedpan on plastic chair for patientˇ¦s bedside toileting use is undesirable and needs to be reviewed.
-On portable X-ray service, the Panel recommends that the Radiology Department should explore means to improve on the arrangements of portable X-ray service during the period of 0800 ˇV 0900 hrs, between night and day shift.
-On communicating with family members of patients in complex cases, the Panel suggests that Ward Manager / Nursing Officer should have more direct and continuous involvement.
-Overall, the Panel recommends a closer look at the nursing care process, to simplify task-oriented duties and to enhance the quality of holistic nursing.
Having considered the Panelˇ¦s recommendations, the hospital will take immediate positive actions as follows:
-To produce information kit for private imaging/CT scan booking, incorporating information such as summary list of hospital contacts, flow-chart of procedural guide
-To explore the feasibility of appropriate use of bedside commode
-To explore means to improve the arrangements of portable X-ray service to reduce transportation time
-To review the existing system on handling patientsˇ¦/relativesˇ¦ complaint. To reinforce the role of ward manager / nursing officer in direct handling of dissatisfactions expressed by relatives
-To enhance the named-nurse (designated case nurse) system to provide more proactive care and support for complex cases
-To review the nursing care delivery model. To simplify non-nursing duties so as to enhance the quality of holistic nursing
The cause of death of Madam CHAN Wun-sikˇ¦s case is currently being under investigation by the Coroner. If deemed necessary, the relatives can appeal to the HA Public Complaints Committee after the Coronerˇ¦s decision is made.
The Report (both English and Chinese versions) is available for viewing on the HA Homepage at:
www.ha.org.hk/investigation_panel/pmh/report_eng.pdf
www.ha.org.hk/investigation_panel/pmh/report_chi.pdf
Ends/Thursday, August 23, 2007
Issued at HKT 19:54
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