The following is issued on behalf of the Hospital Authority:

     ​The spokesperson for Hong Kong Children's Hospital (HKCH) today (June 26) announced the root cause analysis (RCA) report of a previous incident involving a patient who was found in cardiac arrest after a temporary ventilator circuit disconnection:
      
     A 6-year-old boy was admitted to HKCH on December 24, 2025 due to his underlying rare disease. On March 25 this year, he underwent an interventional procedure under general anaesthesia, which was uneventful. Afterwards, he was transferred to the Paediatric Intensive Care Unit (PICU) as planned for ventilator support. At 7.29am on March 26, a nurse found the patient in cardiac arrest. Cardiopulmonary resuscitation was commenced immediately on the patient, and the endotracheal tube connector was found disconnected from the tube and was immediately reconnected to the ventilator circuit. After resuscitation, the patient returned to spontaneous circulation at 7.36am. The hospital subsequently retrieved the patient's physiological monitor records, which revealed that he had asystole from 7.20am.
      
     HKCH is deeply concerned about the incident and made an announcement on March 28. An RCA panel was formed to conduct a thorough investigation and concluded that the root causes included a combination of factors:
         

1. The attending nurse had left the allocated bed and performed medication checking duty outside the audible range of equipment and monitoring alarms, without clinical handover; and
2. There were gaps in the PICU's safety measures, including alarm volume setting standards for medical equipment and monitoring devices, designated nurse partnership and clinical handover arrangements, and the phenomenon of "alarm fatigue" among staff had not been addressed.

 
     The RCA panel has made the following recommendations for improvement:
     

1. Establish a clear in-house policy for PICU nursing staff that explicitly defines the core duties, clinical handover arrangements and designated nurse partnership system, ensuring cross coverage and formal handover before nurses leave the bedside;
2. Ensure initial patient assessment and clinical documentation within a defined timeframe after nurse shift handover;
3. Enhance unit-wide staff training on alarm management for proper alarm responses and reducing "alarm fatigue";
4. Reinforce regular checks on bedside and central monitors to ensure alarm audibility and proper display functions;
5. Provide crew resource management training to optimise teamwork, communication and clinical decision-making among staff to promote patient safety.

 
     HKCH accepted the recommendations of the report and has already begun to implement key improvement measures, including strengthening bedside coverage, handover and equipment safety checks (including alarm volume settings), and will continue to take follow-up actions to enhance patient safety.
      
     The hospital has explained to the patient's parents the report's findings and expressed a sincere apology. HKCH will closely communicate with them and render all necessary support. The patient is still hospitalised in the PICU in serious condition. The clinical team will continue to closely monitor his clinical condition and provide appropriate treatment.
      
     The hospital has been following up with the staff concerned in accordance with prevailing human resources policy, including appropriate disciplinary measures where indicated.
      
     The hospital has submitted the report to the Hospital Authority Head Office and expressed gratitude for the work of the Chairman and members of the RCA panel. The membership of the panel is as follows:
      
Chairman:
Dr Sin Ngai-chuen
Hospital Chief Executive, Alice Ho Miu Ling Nethersole Hospital and Tai Po Hospital
      
Members:
Dr Janice Chow
Consultant, Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital
      
Ms Pilta Kan
Nurse Consultant, Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital
      
Dr Raymond Cheung
Chief Manager (Patient Safety and Risk Management), Hospital Authority
      
Dr Osburga Chan
Service Director (Quality and Safety), Kowloon Central Cluster
      
Dr Eric Chan
Deputy Chief of Service, Department of Paediatrics and Adolescent Medicine, Kwong Wah Hospital
      
Dr Sally Wong
Deputy Quality and Safety Coordinator, Hong Kong Children's Hospital

Ends/Friday, June 26, 2026
Issued at HKT 18:04

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