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Tseung Kwan O Hospital announces sentinel event
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The following is issued on behalf of the Hospital Authority:

     The spokesperson for Tseung Kwan O Hospital today (September 4) announced a sentinel event:

     A 92-year-old female patient who had a history of stroke and dementia was transferred from Haven of Hope Hospital to Tseung Kwan O Hospital on September 2 due to difficulty in reinserting a Ryle's tube for feeding. The patient was admitted to medical ward via Accident and Emergency Department on September 2 at around 3pm. During her stay, a Ryle's tube was inserted by a nurse on the same day at 4pm. Ryle's tube feeding with milk was started on September 3 at noon and the patient was found having difficulty with breathing an hour later.  The patient was resuscitated with airway intubated and was transferred to Intensive Care Unit (ICU) for further management. A doctor reviewed the chest X-ray done on September 2 and found a feeding tube was inserted into the patient's lung instead of stomach. During her stay at ICU, the patient's condition deteriorated and succumbed at 00.02am on September 4. The case had been referred to the Coroner for further follow-up.

     The hospital expresses regret for the death of the patient. The hospital also explained the incident to the patient's family this afternoon with condolence and apology. Necessary assistance will be provided to the family.

     The hospital is highly concerned about the incident and had reported the incident to the Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. An investigation panel will be set up for in-depth investigation. It is expected that the investigation panel report will be completed for submission to the HAHO in six to eight weeks.

Ends/Thursday, September 4, 2014
Issued at HKT 22:32

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