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The following is issued on behalf of the Hospital Authority:
Kowloon Central Cluster of Hospital Authority today (March 17) announces the findings of the Investigation Panel Report on the medical incident of a patient with permanent tracheostomy in Kowloon Hospital (KH).
A 73-year-old male patient suffering from advanced cancer of hypopharynx underwent pharygolaryngectomy surgery in Queen Elizabeth Hospital (QEH) in June 2011. A permanent tracheostomy was made at the throat for breathing. He suffered from stroke afterwards and was transferred to Kowloon Hospital (KH) for rehabilitation. The patient finally passed away on November 14, 2011. It was later found that the gauze over the stoma was inappropriately appended to the skin on all four edges.
Kowloon Central Cluster set up an independent Investigation Panel to investigate the case. The panel found that while the patient undergone rehabilitation in KH, from November 8, 2011 to November 14, 2011, there was a lack of awareness among the involved medical and nursing staff that the patient had a permanent tracheostomy. The tracheostomy was managed as a temporary tracheostomy and the stoma was inappropriately covered by gauze fixed with adhesive tape. It was also found that there was inadequate communication among health care personnel during the transfer of the care of the patient between QEH and KH. The documentation was not adequate to assist the nursing team at KH to be fully aware of the type and the condition of the tracheostomy.
Based on the above findings, the Panel made the following recommendations:
1. To enhance staff education and training. Appropriate education and training should be provided to the healthcare staff at KH so that they are fully aware of how to distinguish between a permanent tracheostomy and a temporary tracheostomy and the appropriate care for each type of tracheostomy.
2. To improve communication upon transfer of patients. When a patient who has a tracheostomy is transferred from one hospital to another, there should be clear and adequate handover notes so that the receiving team in the receiving hospital will be fully aware of the type of tracheostomy and the condition of the tracheostomy.
The Cluster Chief Executive of Kowloon Central Cluster, Dr Hung Chi-tim said that the hospital had accepted the Investigation Report and implemented the Panel's recommendations. The hospital had also met the deceased's family to explain the details of the report. Dr Hobby Cheung, Hospital Chief Executive of KH, expressed his sincere apology and condolences to them again and the hospital would provide assistance as required. The case has been referred to the Coroner for investigation.
Kowloon Central Cluster has followed-up the case according to established human resources procedures and will take appropriate disciplinary actions if there is any misconduct found.
The Cluster has notified the Hospital Authority Head Office of the report findings. Dr Hung expressed his heartfelt gratitude to the Chairman of the Investigation Panel Dr Yu Hip-cho (Chief of Service, Department of Ear, Nose, Throat at QEH) and its members for their endeavours and efforts in completing the report. Other members included: Mr James Yip, Member of Hospital Governing Committee, Kowloon Hospital
Dr T K Poon, Director (Quality & Safety) / Consultant (Psychiatry), Department of Psychiatry, Kowloon Hospital
Dr Jimmy Chan, Hon Associate Professor (Surgery), Division Chief of Head and Neck Surgery, Queen Mary Hospital
Mr S W Ng, Deputy Ward Manager (Medical), Department of Medicine, United Christian Hospital
Ms Katherine Pang, Manager (Patient Safety & Risk Management), Department of Quality & Safety, Hospital Authority Head Office
Ends/Saturday, March 17, 2012
Issued at HKT 21:15
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