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The Department of Health (DH) had completed its investigation into the incident, involving three deaths, which occurred in the Renal Dialysis Unit of the Hong Kong Sanatorium and Hospital on August 20, 1998.

A spokesman for the Department said today (Monday) that while the Investigation Team recognised that haemodialysis is in itself a safe procedure, recommendations to further promote safe practices in the provision of haemodialysis services had been made.

The Department had issued safety guidelines on haemodialysis for institutions providing this service to facilitate them devise their own procedures and guidelines to ensure safety in providing haemodialysis services relevant to their particular clinical settings.

On the investigation of the medical incident, the spokesman noted that an inquest into the three deaths would be held.

In general, the Investigation Team concurred with the findings of the Independent Investigation Committee appointed by the Hospital with regard to the sequence of events leading to the incident.

"The incident was thought to have resulted from contamination of the water treatment system used for haemodialysis. A multitude of factors acted together to result in the event."

"Immediate measures taken by the Hospital in response to the incident were considered generally in order. In the longer term, improvement measures will have to be set in place and reviewed regularly to prevent the occurrence of incidents of similar nature."

"Until such improvement measures have been satisfactorily put in place, the Renal Dialysis Unit should remain closed."

"The Hospital's provisions in relation to accommodation, equipment and staffing at the time of the incident were found appropriate for the purpose of carrying out haemodialysis treatment."

The DH's Investigation Team comprised two doctors and a nurse from the Department. A renal specialist was also appointed to act as expert adviser.

The spokesman added that in considering the Hospital's application for renewal of licence, the Department of Health would take into account the progress and achievements made by the Hospital in implementing the improvement measures.

End/Monday, November 9, 1998

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