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The following is issued on behalf of the Hospital Authority:
The spokesperson for Kowloon Hospital (KH) announced a sentinel event today (November 22):
A 73-year-old male patient suffering from cancer of hypopharynx underwent pharyngolaryngectomy surgery in Queen Elizabeth Hospital (QEH) in June 2011. A tracheostomy (small permanent stoma) was made at the throat for breathing. During the initial post-operative period, a tracheostomy tube was inserted at the stoma. The tracheostomy tube was removed after the patient's condition and the stoma became stable. The stoma was covered with gauze to prevent foreign body from entering the airway. The usual practice is to append the gauze to the skin at the top edge.
The patient was treated in QEH and KH after the surgery and was transferred to KH for rehabilitation on November 8. In the early morning of November 14, the patient's condition suddenly deteriorated. The clinical staff immediately performed cardio-pulmonary resuscitation and the gauze covering the stoma was removed. However, the resuscitation was unsuccessful and the patient finally passed away. It was later found that the gauze over the stoma was inappropriately appended to the skin on all four edges.
The hospital has explained the incident and extended deep condolences to the patient's family with apology. The hospital will maintain close contact with the family and offer necessary assistance as required. The hospital has also referred the case to the Coroner for follow-up.
The hospital is very concerned about the incident. The case has been reported to Hospital Authority (HA) Head Office via the Advanced Incident Reporting System. An investigation panel, comprising experts and external representatives, will be set up to investigate the incident. The report will be completed in eight weeks for submission to HA Head Office.
After the incident, the hospital management has immediately reminded all the frontline staff to strictly comply with clinical protocols. Clinical supervision has been strengthened to prevent recurrence of similar events.
Ends/Tuesday, November 22, 2011
Issued at HKT 21:15
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