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A spokesman for the Department of Health (DH) today (October 20) said that the department was deeply concerned and expressed sincerest regrets to the family for an incident in Fu Shan Public Mortuary, where an autopsy was mistakenly conducted on a body exempted from autopsy. A comprehensive investigation was immediately launched.
The spokesman explained that as Police raised no suspicion on the cause of death on October 17 of a 77-year-old lady with a history of heart disease, her autopsy was waived by the Coroner on the afternoon of October 18 upon her family's request.
However, later on that afternoon, in the course of preparation for autopsies to be done on October 19, the duty mortuary officer mistakenly prepared labels with the woman's name and other personal information, and stapled them to the case notes of a male body which required an autopsy examination.
The mishap continued when mortuary staff picked up the female body by referring to the wrongly prepared label.
A mortuary attendant in fact spotted the mismatch before the autopsy because he discovered a discrepancy in the information between the label and the computer-generated autopsy list. He immediately alerted a medical officer on the spot.
The medical officer checked the number of autopsies to be performed on the day and also the name label on the case notes against the bracelet of the dead body and did not notice any mismatch.
The incident finally came to light when the Senior Medical Officer who performed the autopsy discovered a mismatch between the label and the body he had examined as he prepared specimens for laboratory testing.
The spokesman remarked that the issue was reported immediately to the Coroner yesterday and the situation was also explained to the family.
He said that the department attached greatest importance to the incident.
According to preliminary findings thus far, mistakes seemed to have occurred at several key points in the identification of bodies for autopsy.
"We are determined to plug the loopholes to prevent recurrence. Notwithstanding further findings, with immediate effect, control on critical points will be enhanced and all public mortuaries must observe them.
"Mortuary staff have been instructed to strictly check bodies which require autopsies only against the Coroner's autopsy order and nothing else.
"Moreover, medical officers must recheck bodies against both the autopsy order as well as case notes before moving on to perform autopsies," the spokesman stressed.
"In addition, a Duty Medical Officer system has been introduced in the autopsy room of all public mortuaries to enhance supervision. He is to personally attend to suspicions raised."
He also reassured the family that the department will spare no effort in providing assistance.
Other measures to further improve the services at public mortuaries will be considered after full investigation results are in hand.
Ends/Wednesday, October 20, 2010
Issued at HKT 18:14
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