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The following is issued on behalf of the Hospital Authority:
The spokesperson of Tuen Mun Hospital (TMH) announces a sentinel event today (November 29):
A 69-year-old man with chronic heart disease collapsed during exercise in the morning of November 23. He had his head injured and regained consciousness on arrival to the TMH Accident and Emergency Department, where he received a computerised tomographic (CT) brain scan. The doctor reviewed the images and did not recognise the bleeding inside the brain and there was no clinical sign of acute stroke. The patient was then admitted to the Medical Ward for management of his acute coronary syndrome suggested by the electrocardiography findings.
According to his medical record, the patient requires aspirin and other medications for his heart disease to prevent vascular obstruction. Doctors thus continued to prescribe the patient with aspirin and other drugs to improve the blood flow to the heart muscles. Patient had no clinical sign of acute stroke such as dysphasia or hemiplegia and doctors continued with the management of his cardiac condition. On November 25, the patient's condition deteriorated. He became unresponsive and required ventilator to help his breathing. CT brain examination was repeated and showed that the patient had intra-cranial haemorrhage and his condition was serious. Neurosurgeons assessed the patient and found patient was not suitable for an operation. Doctors at the Department of Medicine continued to manage his intra-cranial haemorrhage and acute myocardial infarction. The patient's condition had no improvement since then. He succumbed on November 27 (Sunday).
The patient's first CT brain scan result was reviewed and found a small area of intra-cranial haemorrhage in the right frontal region. Generally speaking, patient suffering from intra-cranial haemorrhage should not be prescribed anti-platelet agents or anticoagulants.
TMH was saddened by the death of the patient and extended deep condolences to the patient's family. The hospital is very concerned about the incident and will carry out thorough investigation. To enhance risk management, CT scan images of patients with head injuries will be reviewed by doctors in Diagnostic Radiology Department for intra-cranial bleeding before prescribing anti-platelet agents and anticoagulants.
An investigation panel, comprising experts and external representatives, will be set up to investigate the incident and make recommendations for improvement. The report will be completed in eight weeks for submission to Hospital Authority (HA) Head Office.
The hospital has also referred the case to the Coroner. The case has been reported to HA Head Office via the Advanced Incident Reporting System. The hospital has explained the incident and apologised to the family. The hospital will maintain close contact with the family and offer necessary assistance.
Ends/Tuesday, November 29, 2011
Issued at HKT 22:21
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