Queen Elizabeth Hospital announces investigation findings and recommendations in regard to sentinel event
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The spokesperson of Queen Elizabeth Hospital (QEH) today (January 25) announced the findings and recommendations of the investigation report regarding a sentinel event of a case of maternal death.
A 33-year-old woman at gestation of 38 weeks, who received regular antenatal check-ups at QEH, attended the hospital at 10am on November 28 last year after having a bloody show. After conducting an examination, a doctor diagnosed fetal deceleration and admitted the pregnant patient for induction of labour. Medical staff closely monitored the condition of the pregnant patient and her fetus during the induction. Doctors applied vacuum extraction to assist the delivery. The patient delivered at about 9pm on the same evening.
Shortly after delivery, the patient had post-partum haemorrhage and had low blood pressure. Doctors conducted emergency treatment including blood transfusion. However, as the patient's condition deteriorated, doctors conducted an urgent laparotomy at about 11pm to investigate the uterine bleeding. A doctor subsequently decided to conduct an emergency hysterectomy to avert further severe bleeding. The patient developed disseminated intravascular coagulation, resulting in severe bleeding from the uterus. During the operation, the patient suffered cardiac arrest. Medical staff closely communicated with the patient's family and explained the situation to them throughout the procedure. After the operation, the patient was transferred to the Intensive Care Unit (ICU) at about 10am on November 29 for further treatment. However, she finally succumbed at 4.25am on November 30.
The hospital has reported the incident to the Hospital Authority (HA) Head Office via the Advance Incident Reporting System and set up an investigation panel to identify the root causes of the incident. After investigation, the panel came to the following conclusions:
- The Obstetrics and Gynaecology (O&G) Department has a system and measures in place to uphold service quality, including regular review of patients in the labour ward by an appropriate level of doctors. Senior staff are readily available to come in to offer help.
- The patient's degree of shock and tachycardia was not in proportion to the amount of vaginal bleeding, suggesting she might have suffered from other conditions other than bleeding. The clinical team made a working diagnosis as post-partum haemorrhage caused by uterine atony and made every effort to rule out other causes. The team provided thorough and appropriate management for this working diagnosis, including bleeding control manoeuvre and medication, medication promoting uterus contraction, uterine compression suturing, insertion of a Bakri balloon, and promptly conducting fluid resuscitation and blood transfusion. Despite the resuscitative efforts, the patient deteriorated rapidly and became critically ill. The clinical team did not involve the senior doctors of the department and other specialties early.
- The patient was critically ill when arriving at the operating theatre. It was debatable whether one should proceed with the planned hysterectomy or should the patient be sent to the ICU to support the heart and lungs function given that the vaginal bleeding continued. It was even more debatable if the hysterectomy was an appropriate decision when the patient had developed cardiac arrest. Retrospectively, in view of the seriousness and rapidly deteriorating medical condition, the panel opined that the outcome of the patient might not have been any different irrespective of any medical treatment given.
The panel has made the following recommendations to QEH for enhancement of patient safety:
- Sharing the incident with staff of the related departments including O&G, the ICU and anaesthesia to facilitate multi-disciplinary management of critically ill patients.
- Reinforce staff training on identifying and managing critically ill patients.
- Review and revise the protocol on emergency management of critically ill patients including timely escalation of communication with senior staff and other disciplines for management of critically ill patients; early referral to relevant specialties.
- Evaluate and monitor team performance by conducting regular drills with debriefings.
The investigation report has been submitted to the HA Head Office and the panel's recommendations have been accepted. Together with another maternal death case for which an investigation was completed earlier, the hospital has comprehensively reviewed its patient safety measures, and various improvement measures in training and clinical protocols have been put in place.
"The hospital is very concerned about the maternal death incidents that took place in recent months. The medical teams concerned have been receiving simulation training since December last year to enhance their preparedness in management of post-partum haemorrhage and other medical emergencies," the Hospital Chief Executive of QEH, Dr Albert Lo, said.
Dr Lo also expressed his deepest condolences again to the family. The Patient Relations Officer has met the family to explain the investigation report and will continue to closely communicate with them to provide the necessary assistance.
The hospital expressed its gratitude to the Chairman and members of the Investigation Panel. Membership of the panel is as follows:
Chairman
Chief of Service (O&G Department), Prince of Wales Hospital, Dr Cheung Tak-hong
Members
Senior Manager (Patient Safety and Risk Management), Quality and Safety Division, HA Head Office, Dr Venus Siu
Cluster Service Coordinator (Medical Stream), Kowloon Central Cluster, Dr Ho Hiu-fai
Service Director (Quality and Safety), Kowloon Central Cluster, Dr Osburga Chan
Deputy Service Director (Quality and Safety), New Territories West Cluster, Dr Kwan Wai-man
Midwife Consultant (O&G Department), Princess Margaret Hospital, Ms Ho Lai-fong
Ends/Wednesday, January 25, 2017
Issued at HKT 17:45
Issued at HKT 17:45
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