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The following is issued on behalf of the Hospital Authority:
The spokesperson of Shatin Hospital (SH) made the following announcement today (June 7) regarding the investigation report on an incident of death certification for a patient:
SH announced an incident of suspected negligence in certifying the death of a patient on April 7, 2016. A panel was subsequently set up for an investigation and to make recommendations to prevent reoccurrence. The panel has completed the investigation with the report being submitted to SH.
The incident involved an 87-year-old male in-patient of a Medical and Geriatrics Ward who was deteriorating and dying in the morning on March 30 due to his own clinical condition. With the agreement of the patient's family members to "Do Not Attempt Cardiopulmonary Resuscitation", a nurse on duty informed the family of the patient's deteriorating condition. At 10.55am, the diagnostic electrocardiography device showed that the heartbeat of the patient had completely stopped and the blood pressure and pulse were unmeasurable. Another nurse on duty informed a doctor that the patient had passed away. Due to being engaged by other clinical duties, the doctor did not certify the death of the patient and did not make documentation on the medical record.
Later, at around 11am, after family members had arrived for viewing the deceased patient, a nurse on duty started last offices at around noon with the agreement of the deceased's family and arranged for mortuary staff to take the body from the ward to the mortuary. The nurse did not check if the process was completed before sending out the body from the ward while the doctor was still engaged with other clinical duties.
The doctor then left the ward to perform other clinical duties. When the doctor returned to the ward at around 2pm, it was found that the death certification had not been completed and he went to the mortuary to complete the procedures. However, the ward concerned did not report the incident to the hospital according to standard procedures.
The hospital management learnt about the incident on April 6 and immediately notified the Hospital Authority Head Office via the Advance Incident Reporting System after confirmation of the incident. The hospital also informed the family of the deceased patient and apologised. The body collection process by the family of the deceased was not affected. The incident was disclosed to the public on April 7 and an investigation was carried out.
The investigation panel interviewed the staff concerned and examined the workflows. The panel has concluded in its findings that the following three factors are believed to have contributed to the incident:
1. The two nurses assumed that the doctor had completed death certification and documentation. They did not reconfirm if the procedures had been completed;
2. There was no final checking of the completeness of the documentation in the patient's medical record before sending the deceased's body to the mortuary; and
3. The communication among healthcare providers was inadequate.
The investigation panel has made the following recommendations to the hospital:
1. To enhance the compliance of nursing staff on following the existing practice strictly, including the checking of the deceased's death documentation before sending the body to the mortuary;
2. To reinforce clinical supervision and redefine roles and responsibilities of staff;
3. To enhance communication skills and handover among healthcare providers; and
4. To reinforce incident reporting by staff, on strictly following standard incident reporting procedures.
SH has accepted the recommendations to prevent similar incidents from happening again and the incident will be followed up in accordance with human resources policy. The hospital has also explained the investigation findings to the family with sincere apologies again. SH expresses appreciation to the Chairman and members of the investigation panel for their efforts in the investigation. Membership of the panel is as follows:
Chairman:
Dr Herman Lau
Clinical Stream Coordinator (Allied Health Services), New Territories East Cluster
Hospital Chief Executive, Cheshire Home, Shatin
Members:
Dr So Wing-yee
Deputy Service Director (Quality and Safety)
New Territories East Cluster
Mr Kwan Siu-yuk
General Manager (Nursing)
Kowloon Hospital
Dr Tsang Wai-kong
Associate Consultant (Clinical Oncology)
Prince of Wales Hospital
Ms Chan Kit-hoi
Department Operations Manager (Medicine and Intensive Care Unit)
Alice Ho Miu Ling Nethersole Hospital
Ends/Tuesday, June 7, 2016
Issued at HKT 19:03
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