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The following is issued on behalf of the Hospital Authority:
The spokesperson for Yan Chai Hospital (YCH) made the following announcement today (March 16) regarding a sentinel event:
A 70-year-old female patient with underlying coronary heart disease, heart failure, atrial fibrillation and multiple heart attacks was admitted for percutaneous coronary intervention (PCI). The PCI was conducted at Princess Margaret Hospital (PMH) by Yan Chai Hospital (YCH) cardiologists on March 10. Three drug-eluting stents were intended for deployment at appropriate locations of coronary arteries and to be expanded to maintain blood flow in coronary vessels.
During the PCI procedure, one of the unopened stents needed to be retrieved as its deployment failed. The retrieval was considered to be completed. The other two stents were expanded and deployed correctly in different locations of coronary arteries and all coronary blood flow was satisfactory. The patient was then admitted to the Coronary Care Unit of PMH for further monitoring.
The patient's condition deteriorated in the subsequent hours. Cardiologists suspected it may be related to the retention of the unexpanded stent. On March 11, YCH cardiologists conducted cardiac catheterization and confirmed that the unexpanded stent, which was considered to have been retrieved during the preceding day's procedure, had been retained in one of the coronary arteries while blood flow was not impaired. To manage the deteriorating condition of the patient, another coronary stent was deployed over this retained stent. The medical team involved met the family members immediately after the procedure to explain the incident in detail with an apology.
The patient's condition continued to deteriorate and she was admitted to the Intensive Care Unit at PMH for further monitoring. The patient succumbed at 6.30am today (March 16). The hospital expresses its deepest condolences to the family members and will continue to liaise with the family to provide all necessary assistance.
The case has been reported to the Coroner for follow up and also to the Hospital Authority Head Office (HAHO) under the system of Advanced Incidents Reporting System. An investigation panel will be set up to investigate the incident. The investigation report will be submitted to the HAHO in eight weeks' time.
Ends/Monday, March 16, 2015
Issued at HKT 19:15
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