• Tue
  • Sep 23, 2014
  • Updated: 10:29am
NewsHong Kong

Elderly woman dies in Hong Kong hospital after feeding tube is mistakenly inserted into her lung

Tseung Kwan O Hospital apologises and launches investigation

PUBLISHED : Friday, 05 September, 2014, 1:25pm
UPDATED : Saturday, 06 September, 2014, 3:46am

Tseung Kwan O Hospital has apologised to the family of a 92-year-old woman who died after a feeding tube was inserted into her lung instead of her stomach.

The woman, who had suffered a stroke and had dementia, was transferred to the hospital on Tuesday from the nearby Haven of Hope Hospital, which specialises in geriatric care.

A nurse inserted the tube at 4pm that day. An X-ray was also carried out. Milk was fed through the tube at noon on Wednesday; an hour later the patient began to have trouble breathing.

She was admitted to intensive care where a doctor reviewed the X-ray and discovered the error. She died just after midnight.

Louis Shih Tai-cho, president of the Medical Association, said inquiries should focus on why a doctor had initially failed to spot the mistake from the X-ray, which he said should have been easy to see. "Specialists should be reviewing an image if it is too blurry or if the stomach is overlapping the lung," he added.

"This is a serious issue," the Patients' Right Association said.

A spokeswoman for the hospital said it was investigating and a report was expected to be ready within three months. "We have explained the incident to the patient's family with our condolences and an apology," she said. "The hospital is highly concerned about the incident."

The coroner has been alerted.

Separately, another 92-year-old Haven of Hope patient with congestive heart failure and respiratory failure was found to have had his 3ml per hour intravenous dosage of dopamine set at 100ml on September 2. The error was spotted later that day and the patient was transferred to the United Christian Hospital, Kwun Tong, but died in the early hours of September 4. The case has been referred to the coroner.



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This article is now closed to comments

I hope the hospital will get sued. This is criminally negligent manslaughter!
"Oops" -- HK Hospital Authority
This kind of incidents happens around the world. For NHS in UK, over 20 deaths and 80 incidents related to misplacement of feeding tube within 5 years (2005-2010). This counts for those reported cases only.
I know.
The X-ray film after feeding tube insertion is the best way to confirm the tube placement. This screening and confirmation is performed by doctor and not radiographer. If the doctor already screened the film to confirm it's in situ, he/she shall document clearly before start feeding. So for this case, it's either the doctor haven't screened the film or the doctor failed to recognize the misplacement. Normally the nurse would perform tube aspiration or auscultation to check for tube placement before each feeding. However, a similar gurgling sound could be heard over epigastrium if the tube end was in tracheobronchial tree and thus this method is not totally reliable.
Maybe the nurse doing the procedure was too busy taking selfies?
Are smartphones banned in hospitals yet, among staff?
FFS. Do they train these people?
The statistics are too astoundingly uncanny as coincidental and these malpractices are either one or all of the following from negligent medical personnel:
1. Overwork that leads to diminishing professional accuracy
2. Sub par medical programs in HK medical schools
3. Lack of passion and Lack of ACCOUNTABLITY because years of turning a blind eye from the medical council.
Either way this a freak accident and the culprit should be put on criminal trial as they would in the west. The poor old lady who is deprived from a natural death, even near the end of her lifeline. Totally despicable.
Let's see: a radiographer does imagining to confirm proper placement of a feeding tube and does not notice the feeding tube is in the lung not the nasopharyngeal area. A radiologist does or does not read the image and sign off prior to being put into a bed? A nurse connects milk into a feeding tube and nothing is noticed. Perhaps Hong Kong is hiding something from the public about quality and management beyond what we hear about?
Much more bad things happen in Queen Elizabeth Hospital.




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