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Mortuary boss in cover-up

Ella Lee

Pamela Youde Eastern Hospital said last night it would hold disciplinary hearings on two mortuary staff, whose dishonesty and poor management were blamed for the loss of a baby's body in December.

The five-member investigation panel, set up by the Hospital Authority after the loss was revealed last month, released its findings last night. It concluded that the body of the newborn boy was lost some time between December 17 and 19 'unintentionally due to human errors'.

The report revealed that a mortuary technician, who oversees the daily operation of the mortary and is an immediate supervisor to four mortuary assistants, had tried to cover up the incident for five days.

The technician had previously told management and the police that he last saw the baby's body on December 19. But he told the panel he had lied - and that he had failed to update the body's identification wristband when the birth certificate was presented to him.

The confession raised concerns that the five-day police search of medical waste dumped in Tseung Kwan O landfill on December 20 and 21 had been a waste of time.

The report said the frontline workers made a number of mistakes at different stages in the incident.

'However, the mistakes have at least partially arisen from poor systems of work resulting from insufficient supervision and management in the mortuary,' it said.

Reacting to the findings, hospital chief executive Loretta Yam Yin-chun said the mortuary technician and his supervisor, an administrative assistant, would face disciplinary hearings for 'serious misconduct'.

'The mortuary technician has provided misleading information; such serious misconduct has created many problems,' she said.

'The administrative assistant failed to properly supervise the mortuary operation. Their performance is far from satisfactory and is well below the standards of the Hospital Authority.'

Dr Yam apologised for the incident, which she said had used up a lot of hospital and police resources.

'I sincerely apologise to the parents, society and police ... The hospital will not evade giving out compensation to the parents. However, we understand that nothing can compensate the parents for their suffering and pain,' she said.

A police spokeswoman said the investigation was completed, no criminal element had been found and no evidence supported another search of the landfill. The police will seek advice from the Department of Justice regarding the case.

The disciplinary hearings on the two staff will start next week and are expected to take four weeks. Possible punishments include warnings, suspension and sacking. The mortuary technician has been suspended for the duration of the hearing.

The baby was born prematurely and died on December 15 after surviving for about two hours. His body was sent to the mortuary that day and an adult man's body was put in the same tray on December 17.

The panel identified two 'critical points' in the case: when the man's body was transferred to share the baby's tray on December 17, and when the man's body was released to relatives on December 19.

A mortuary assistant (MA1), who placed the boy on the thighs of the man's body in the tray, told the panel he had reported to the technician on December 31 that the baby's body was missing. MA1 told the panel he was asked by the mortuary technician to wait for clarification from another mortuary assistant, MA3, who handled the adult's body. It was not until January 5 that the technician reported the loss to management.

The technician admitted to the panel he had lied to management that the body was found missing on January 2, when MA1 had reported its loss to him on December 31.

The panel found the technician and MA1 and MA3 had all given 'inconsistent and unreliable evidence'.

It said the technician gave the 'most unreliable evidence' and it was a 'breach of duty' that he had failed to update the boy's identification. The panel was of the opinion he was attempting to cover the facts.

Dr Yam said MA3, who had been suspended, would now be allowed to resume work.

The report also criticised the practice of putting two bodies in a tray when 27 of the 114 trays in the mortuary at the time were vacant. It said the mortuary lacked supervision.

Search for truth

The findings of the investigation panel looking into the disappearance of the baby's body contradict the sequence of events provided by police and the hospital

The main players

Who was involved, and what the panel believes went wrong

Eastern Hospital chief executive Loretta Yam Role: oversees policy and operation of hospital

Department of Pathology's cluster chief of service (COS) Role: sets departmental policy and development plans, directs implementation and attends to the autopsy service Problem: Delegated the management of the mortuary to the department manager

Department Manager (DM) Role: manages and supervises daily operations of laboratories in Hong Kong East cluster and mortuary services at Pamela Youde Nethersole Eastern Hospital Problem: had little knowledge about mortuary's day-to-day operations

Administrative assistant (AA) Role: arranges mortuary attendants' duties; provides updated guidelines on handling of bodies Problem: only realised after the incident that staff had not acted according to his instructions on body identification and the risks of putting two bodies in one tray

Mortuary technician (MT) Role: monitors body collection and transfer, and verifies daily body collection statistics Problem: admitted lying about when he last saw the baby's body and delayed reporting it missing

Mortuary attendants (MA 1, 2, 3, 4) Role: dispose of tissue and organs after autopsies; maintain records of bodies Problem: M1 put two bodies together; he and M3 gave inconsistent and unreliable evidence

The sequence of events

Original story of mortuary staff

Dec 15: Baby boy dies and body placed in mortuary

Dec 17: Adult body put in same compartment

Dec 19: Baby's body last seen in mortuary and adult body released to relatives

Jan 2: Mortuary technician (MT) finds baby's body missing amid routine inspection

Jan 5: Technician reports case to hospital management; hospital reports to police

Panel's findings

Dec 15: Baby boy dies and body placed in mortuary

Dec 17: Adult body put in same compartment by mortuary assistants 1 and 2; body of baby last seen in mortuary

Dec 19: Adult body released to relatives; MT later admits lying and did not see baby's body that day

Dec 31: MA1 finds baby's body missing and reports to MT

Jan 5: MT reports case to hospital management; hospital then reports to police

Jan 12: Police start five-day search of landfill waste dumped in Dec 20 and 21

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