Queen Elizabeth Hospital announces investigation findings on sentinel event
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The spokesperson of Queen Elizabeth Hospital (QEH) today (December 21) announced the findings of the Investigation Panel regarding a sentinel event involving a case of maternal death.
The sentinel event was announced by the hospital on October 11 this year. A 26-year-old pregnant woman had an antenatal check-up at QEH at gestation of 37 weeks in the morning on October 6, and was found to have pre-eclampsia with proteinuria and hypertension. She was thus admitted for induction of labour. The conditions of mother and her foetus were closely monitored during the delivery process. She had a delivery at about 7pm on the same day. The baby girl was in stable condition. Shortly after delivery, the mother developed post-partum haemorrhage. Uterine atony was diagnosed. Doctors immediately provided emergency treatment to control the bleeding, including administration of coagulant medications, blood transfusion and insertion of an intra-uterine balloon. Initial examination of the placenta by the clinical team found it to be complete. Further ultrasound examination did not reveal retained product of gestation.
However, the patient's condition further deteriorated and she required resuscitation at about 10pm on the same day. The patient's condition was complicated with disseminated intravascular coagulation (DIC), resulting in uncontrolled bleeding. Doctors explained the situation to the family and decided to conduct an emergency hysterectomy to avert further severe bleeding.
The patient was transferred to the Intensive Care Unit for management. She required massive blood transfusion and multiple doses of coagulant medications, and underwent two emergency procedures to control bleeding at about 2am and 6am on October 7. She was also suffering from multiple organ failure. The patient's condition deteriorated again on October 9, requiring a third urgent procedure at about 7am. The patient finally succumbed at 11am despite resuscitation. Subsequent pathological examination of the uterus found that a small patch of adherent placenta was retained inside the uterus.
The hospital reported the incident to Hospital Authority (HA) Head Office via the Advance Incident Reporting System and set up an investigation panel to identify the root causes of the incident. After investigation, the panel came to the following conclusions:
- The massive post-partum haemorrhage was caused by uterine atony and aggravated by retained product of gestation in the uterus, leading to subsequent severe DIC;
- The patient's condition had improved initially in response to various treatments to stop the bleeding and this falsely reassured the clinical team that the post-partum haemorrhage was under control. The patient's early signs of shock due to post-partum haemorrhage were not recognised promptly; and
- The findings of complete placenta after delivery led the clinical team to focus on the management of uterine atony on top of other diagnoses.
- The hospital should review and revise the management protocol for post-partum haemorrhage, including timely assessment of the patient after placement of an intra-uterine balloon and timely escalation of treatment if initial response is not optimal; and
- The hospital should reinforce staff training on early recognition and management of post-partum haemorrhage and evaluate and monitor team performance through regular drills.
The spokesperson added that the investigation report was submitted to the HA Head Office and the panel's recommendations have been accepted, including enhancing the preparedness of clinical teams (including the Obstetrics and Gynaecology Department, Anaesthesia and Operating Theatre Services and the Intensive Care Unit) for the management of post-partum haemorrhage. The hospital will also provide more simulated training on emergency management of post-partum haemorrhage and increase the manpower of the obstetric team for handling emergencies. Once again, QEH expresses its deepest condolences to the family over the death of the patient and Patient Relations Officer 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 root cause analysis panel. Membership of the panel is as follows:
Chairman
Chief of Service (Obstetrics & Gynaecology), Kwong Wah Hospital, Dr Leung Wing-cheong
Members
Service Director (Quality and Safety), Kowloon Central Cluster, Dr Osburga Chan
Consultant (Anaesthesia & Intensive Care), Prince of Wales Hospital, Dr Florence Yap
Associate Consultant (Anaesthesia & OT Services), QEH, Dr Samantha Lee
Department Operation Manager (Obstetrics & Gynaecology), Tuen Mun Hospital, Ms Vera Yim
Chief Manager (Patient Safety & Risk Management), Quality & Safety Division, HA Head Office, Dr Sin Ngai-chuen
Ends/Wednesday, December 21, 2016
Issued at HKT 17:00
Issued at HKT 17:00
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