Kowloon Hospital staff's fatal mistake 'entirely feasible': CUHK professor

It is possible cancer sufferer's airway was covered by gauze in error, says professor

PUBLISHED : Tuesday, 29 January, 2013, 12:00am
UPDATED : Tuesday, 29 January, 2013, 4:32am

Medical staff at Kowloon Hospital may have mistaken a breathing hole in a patient's neck for a wound that needed bandaging, an inquest into his 2011 death heard yesterday.

Chinese University medical professor Alexander Vlantis told the inquest it was "entirely feasible" that staff at Kowloon Hospital - and possibly nurses at Queen Elizabeth Hospital - mistakenly assumed the patient had "a tracheostomy [a wound] and not a tracheal stoma [an artificial opening created by surgery]."

The patient, Wang Keng-kao, 73, died in Kowloon Hospital on November 14, 2011, after he was transferred there following cancer surgery at Queen Elizabeth Hospital in June.

Vlantis said the staff may have assumed the stoma was a wound that needed a dressing until it healed. But, he noted: "Covering it [a permanent opening] with gauze was completely incorrect."

Rather, a laryngectomy bib or laryngectomy apron could have been worn around the neck of the patient to prevent sputum being coughed into his surroundings, Vlantis said.

When asked by the Hospital Authority's lawyer if a piece of gauze was sometimes used to mimic an apron, the professor said such practice was "extremely dangerous".

At both hospitals, medical notes for Wang regularly used the incorrect term "tracheostomy", which could have led to the incorrect treatment, he said.

Wang's son, Brian Wang Ping-wan, earlier told the inquest that when he went to the hospital on November 6, he discovered the opening in his father's neck was covered by a piece of gauze that was secured with tape.

This remained the case when Wang returned to the hospital on November 13 for what would be his last visit to his father.

Pathologist Dr Cheuk Wah told the Coroner's Court on Friday that the autopsy found in Wang's bronchial tubes, a pocket tissue-sized piece of gauze which obstructed his upper airway and caused his death, Cheuk said.

"As the gauze seemed only to be changed once a day, in the morning, it is possible that it became saturated with sputum or mucus," Vlantis said. "It is not possible to breathe through gauze saturated with mucus."

Wang might have inhaled the piece of gauze during one of his laboured efforts to draw breath, Vlantis said.

Brian Wang told the hearing: "The medical staff [were] unprofessional." Careful daily checks of his father's stoma could have prevented his death, he said.

Meanwhile, Kowloon Hospital's general manager for nursing, Kwan Siu-yuk, said training sessions had been organised to help nursing staff better distinguish wounds from stomas.

Coroner Michael Chan Pik-kiu will give his verdict today.