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The following is issued on behalf of the Hospital Authority:
The investigation panel appointed by the Cluster Chief Executive of Kowloon West Cluster has completed its investigation into the scalding of a three-month-old baby while being bathed in Princess Margaret Hospital (PMH). The investigation report was announced today (April 29). The full investigation report is available at the Hospital Authority (HA) website: www.ha.org.hk/report/PMH100429E .
The Cluster Chief Executive, Dr Tung Sau-ying expressed her heartfelt gratitude to the five panel members for their hard work and efforts in assisting the hospital to investigate the incident. She and Dr Li Chi-kong, chairman of the investigation panel, met the baby's parents at noon today to explain the details of the report and the hospital's follow up measures, and again expressed her sincere apology and sympathy to them.
The investigation panel, established on April 12 has investigated the facts and circumstances surrounding the incident and made recommendations on improvement measures.
According to the report, the concerned nurse admitted that she only tested the water temperature with her hand. She had not followed stipulated guidelines to test the water temperature with her elbow. The panel considered that the baby's injury was a result of scalding by immersion in water probably at around 45 degree Celsius during a bath on April 9. The temperature was hot enough to cause a second-degree scald injury.
"The nurse had not tested the water with her elbow, which is a standard nursing practice. There is obviously a human error. Hence, appropriate disciplinary actions will be taken in accordance with the Human Resources Policies of the HA. Furthermore, the hospital will proactively follow up with the parents of the baby on liability issues," Dr Tung said.
The nurse concerned is currently on leave and will be deployed away from the paediatric ward upon resumption of duty.
"While we deeply regret this unfortunate event, we are relieved to know that the baby has made a good recovery, according to Queen Mary Hospital," Dr Tung added. She said that PMH will continue to follow up on the baby's recovery progress after discharge.
Based on the panel's recommendations, the hospital will take immediate actions as follows:-
- Strict reinforcement of compliance with testing water temperature by elbow
- In addition to elbow testing, water temperature will be tested by bath thermometer before bathing at-risk patients e.g. babies and small children
- Install devices that regulate the maximum water temperature at the faucets of wards caring for at-risk patients
- Strengthen audits on staff's compliance with guidelines on nursing practice
Dr Tung said she fully understands the concern of all the parents who have entrusted the care of their babies to the hospital and reassured them that the improvement measures will be implemented to prevent a recurrence of the incident.
Ends/Thursday, April 29, 2010
Issued at HKT 18:02
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