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Queen Mary Hospital investigation report on post-operative care of paediatric patient
The following is issued on behalf of the Hospital Authority:

  In response to the concerns expressed earlier by the parents of a paediatric patient towards the patient's post-operative care, Queen Mary Hospital (QMH) has invited clinical experts in paediatrics and resuscitation to review the care process. Upon completion of the investigation, QMH today (March 19) explained the report to the parents and announced the key findings of the investigation report.

  Besides meeting related clinical staff and the parents, the panel reviewed the medical records and the ward management situation, and replicated the sequence of events on that particular day.

  The panel noted that, while a bed in the Paediatric Intensive Care Unit (PICU) had been reserved by the clinical team before the operation, the subsequent decision for post-operation admission to the paediatric surgery ward was based on clinical judgement.

  Regarding the decision, the panel consulted both local and overseas experts and confirmed that the patient's clinical condition did not indicate for PICU admission. With due consideration of the past record and previous experience of the paediatric surgery ward in post-operative care, the admission decision was considered acceptable and did not deviate from international practice. However, the panel concluded that the communication between the clinical team and relatives was ineffective regarding the post-operation admission arrangement.

  The panel found that healthcare staff responded to the acute deterioration of the patient one hour after admission to the paediatric surgery ward. However, certain healthcare staff members were inexperienced in recognising the continuous deterioration of the patient, and resorted to their learned behaviour and over-reliance on using the monitoring device.

  During the investigation, the panel could not elucidate the cause of the acute deterioration of the patient, but a number of possibilities were ruled out including medication error, air embolism, problems with the catheter or its position, and unrecognised arrhythmia.

  The panel made the following recommendations to prevent a recurrence of the event:
  1. Cultivate a culture of speaking up, especially when there is a clinical emergency;
  2. Encourage team management for handling deteriorating patient;
  3. Remind staff that physical assessment is equally as important as medical equipment in detection or monitoring vital signs in all patients;
  4. Strengthen awareness of the importance of effective communication between medical professionals with relatives; review and enhance the informed consent procedures; and
  5. Ward management should establish a response plan for a sudden surge in ward activity, as well as regular reviews of supporting provision and training at the inception of changing service mode.

  QMH expressed gratitude to the investigation panel and accepted all the findings. The hospital will implement improvement measures according to the recommendations, including the review of the ward staff establishment and training, and follow-up actions in accordance with established human resources policy.

  The investigation panel has explained the report to the family. The hospital expressed an apology to the patient and the family for the happenings after the event; and will continue to maintain close contact with the family and provide appropriate treatment to the patient.

     Membership of the panel is as follows:
Consultant, Paediatrics and Adolescent Medicine Department, Duchess of Kent Children's Hospital
cum Deputising Hospital Chief Executive, Duchess of Kent Children's Hospital/ Tung Wah Group of Hospitals Fung Yiu King Hospital/ MacLehose Medical Rehabilitation Centre
Dr Lee So-lun

Chairman, Hong Kong West Cluster Resuscitation Committee
Dr Chan Wai-ming

Nurse Consultant, Neonatal Intensive Care Unit, QMH
Ms Lee Wan-ming

Consultant, Paediatrics and Adolescent Medicine Department, QMH
Dr Ng Yiu-ki

Chief Manager (Patient Safety & Risk Management), Hospital Authority
Dr Sin Ngai-chuen
Ends/Monday, March 19, 2018
Issued at HKT 17:57
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