The following is issued on behalf of the Hospital Authority:

     ​The spokesperson for Tuen Mun Hospital (TMH) made the following announcement today (May 14) regarding a sentinel event:
 
     A 75-year-old male patient with chronic obstructive pulmonary disease (COPD) and hyperlipidemia was admitted to a medical and geriatric ward in TMH on May 6 due to an exacerbation of COPD. He was diagnosed with acute coronary syndrome complicated by myocardial infarction and was arranged to undergo for Percutaneous Coronary Intervention (PCI) on May 11.
      
     During the procedure, coronary angiogram revealed an air bubble in the patient's artery. The clinical team immediately checked the blood pressure monitoring device and other connected equipment. No abnormality was detected. The patient's condition remained stable and the clinical team proceeded with the procedure after clinical assessment, with close monitoring of the equipment and the patient's condition. After about 30 minutes, multiple air bubbles were detected again in patient's artery. The patient subsequently developed bradycardia and hypotension. Resuscitation was initiated immediately. The patient continued to deteriorate and succumbed on the same day.
      
     Upon initial inspection of the procedure and the used equipment, clinical team identified an abnormality in the luer lock connector of an extension tube. In general, catheters, connectors and related devices used in PCI procedures should be airtight to prevent micro air emboli entering the bloodstream.
      
     The hospital was saddened by the passing away of the patient. TMH team has interviewed with the patient's family to explain the incident and express deepest condolence. The hospital will maintain close communication with the family and offer possible assistance.
      
     The incident has been reported to the Hospital Authority Head Office (HAHO) via the Advance Incident Reporting System. A Root Cause Analysis Panel is set up to look into the incident. The scope of the investigation will include the related equipment, procedures, operations and other possible contributing factors. A report with proposed recommendations will be submitted to the HAHO within eight weeks. The incident has been reported to the concerned manufacturer of the equipment and the Department of Health for follow-up. The incident has also been reported to the Coroner for follow-up.
 
     Membership of the panel is as follows:

Chairperson:
Dr Carmen Chan
Deputy Chief of Service (Medicine), Queen Mary Hospital
 
Members:
Ms Chi Chui-yee
Department Operations Manager (Medicine and Geriatrics), Tuen Mun Hospital
 
Dr Raymond Cheung
Chief Manager (Patient Safety and Risk Management), Hospital Authority
 
Dr Tam Li-wah
Chief of Service (Medicine and Geriatrics), Kwong Wah Hospital / Tung Wah Group Of Hospitals Wong Tai Sin Hospital
 
Dr Wong Chi-wing
Consultant (Medicine and Geriatrics), Pok Oi Hospital / Tin Shui Wai Hospital
 
Mr Bill Wang
Vice-Chairman, Hong Kong Kidney Foundation
 
Ms Gigi Yiu
Nurse Consultant (Cardiac Care), New Territories East Cluster

Ends/Thursday, May 14, 2026
Issued at HKT 20:10

NNNN