Queen Elizabeth Hospital announces investigation findings of sentinel event
The spokesperson of Queen Elizabeth Hospital (QEH) today (October 12) announced the findings of the investigation report regarding a sentinel event of a case of maternal death.
A 24-year-old pregnant woman who had been receiving regular antenatal check-ups at QEH was diagnosed with oligohydramnios and proteinuria. The woman was admitted for induction of labour during gestation of 38 weeks. She was admitted in the morning on August 10, 2018, to receive induction of labour with the use of medication. The medical staff closely monitored her condition and the foetus. Their conditions were both stable at the time. In the evening, the woman suddenly developed a short duration of seizure and the medical staff immediately examined and monitored her condition. She developed cardiac arrest a few minutes later. The medical staff immediately performed resuscitation and an emergency bedside caesarean section for her. A baby was delivered subsequently. During the process, the medical staff continued to perform resuscitation for the woman, but her condition was still critical with repeated occurrence of cardiac arrest. The woman finally succumbed on August 11.
The hospital reported the incident to the Hospital Authority (HA) Head Office via the Advance Incident Reporting System and set up a Root Cause Analysis (RCA) Panel to investigate the incident. After a thorough investigation, the Panel has completed the report with the following conclusions:
- The woman had a history of proteinuria at 33 weeks of gestation and oligohydramnios at 35 weeks of gestation. A doctor admitted her for induction of labour during gestation of 38 weeks. The management was reasonable;
- The woman's sudden deterioration of condition was without signs and unpredictable but was promptly recognised. The medical staff immediately performed resuscitation. During the process, the medical staff performed cardiopulmonary resuscitation, intubation and blood transfusion in accordance with the international guidelines, and closely communicated with her husband and relatives;
- When the woman's condition suddenly deteriorated and she developed cardiac arrest, senior medical staff from various specialties, including Obstetrics and Gynaecology, Anaesthesiology and the Intensive Care Unit, arrived at the ward immediately to assist in the resuscitation, and made every endeavour to save and revive the woman and the baby. The resuscitation process was prompt, appropriate and thorough;
- An emergency caesarean section was conducted within four minutes after the woman's cardiac arrest and the baby was later delivered. The caesarean section was prompt and proper in accordance with the international guidelines. The baby was discharged from hospital 18 days after birth;
- The woman developed post-partum haemorrhage about one hour after the cardiac arrest. According to her clinical conditions, the cause resembled an amniotic fluid embolism resulting in disseminated intravascular coagulopathy and uterine atony. The multi-disciplinary clinical teams had already provided various resuscitative treatments, blood transfusion and medications; and
- The probable differential diagnoses had been considered by the multi-disciplinary clinical teams upon the sudden deterioration of the woman's condition. They had endeavoured to provide all possible resuscitation and treatments.
The spokesperson said the hospital had accepted the panel's investigation report and had submitted it to the HA Head Office. The hospital has met the family to explain the investigation report and also expressed its deepest condolences once again to the family over the death of the woman, and will continue to closely communicate with the family to provide the necessary assistance.
The hospital also expressed its gratitude to the Chairman and members of the RCA Panel. Membership of the Panel is as follows:
- Dr Leung Wing-cheong, Chief of Service, Department of Obstetrics and Gynaecology, Kwong Wah Hospital
- Dr Lee Kai-wan, Chief of Service, Department of Obstetrics and Gynaecology, Caritas Medical Centre/Princess Margaret Hospital/Yan Chai Hospital
- Dr Shum Hoi-ping, Consultant, Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital
- Ms Lai Sui-yi, Department Operations Manager, Department of Obstetrics and Gynaecology, United Christian Hospital
- Dr Osburga Chan, Service Director, Department of Quality and Safety, Kowloon Central Cluster/Queen Elizabeth Hospital
- Ms Katherine Pang, Manager, Patient Safety and Risk Management, Quality and Safety Division, HA Head Office
Ends/Friday, October 12, 2018
Issued at HKT 19:36
Issued at HKT 19:36