Hong Kong health minister calls for review after hospital error leads to patient getting cancer news four months late
United Christian Hospital’s obstetrics and gynaecology department did not receive reports generated by laboratory information system
The health minister has called for a review of operational procedures in the city’s public hospitals, after a patient at United Christian Hospital was notified that she exhibited signs of ovarian cancer only after a four-month delay.
The obstetrics and gynaecology department did not receive reports generated by the hospital’s laboratory information system, so her doctor learned the results four months after the patient’s specimen was sent to the lab after her operation.
Secretary for Food and Health Dr Ko Wing-man said: “If there was a problem in one step, would it reflect a bigger problem? Would there be bigger problems in other hospitals too?”
He added that United Christian Hospital and the Hospital Authority should review their operational procedures and look for ways to rectify any problems.
A gynaecologist warned that a late report could lead to delayed treatment and difficulty controlling the illness if the cancer was advanced.
The hospital in Kwun Tong has apologised to the patient and said that it would arrange “timely and appropriate treatment” for her. An investigation panel has been formed, and a report will be submitted within eight weeks.
The 52-year-old patient underwent an operation to remove her fallopian tubes and ovaries on December 8 last year. She had been referred to the hospital’s obstetric and gynaecology specialist outpatient clinic by her private doctor in June for follow-up treatment for a right ovarian cyst.
No features of cancer were identified during the procedure.
Her specimens were then sent for histopathology examination – a microscopic inspection of tissues.
The patient was discharged two days after the surgery and was scheduled for a follow-up appointment on April 11, which was when her doctor learned for the first time that her right ovary had carried cancer cells.
A computed tomography scan two days later did not detect any suspicious mass or abnormal tissues in the patient’s abdomen and pelvis. She is due for a follow-up consultation on Friday, when the hospital will provide a detailed explanation.
Private gynaecologist Dr Kun Ka-yan said the surgical removal of the patient's ovaries was a complete treatment for early-stage cancer. However, the late report also meant a delay in treatment, which could result in further issues if the disease was found to be more advanced.
“Chemotherapy might not be adequate to control the condition,” said Kun.
He said it would be difficult to see symptoms of early-stage cancer during an operation.
The hospital learned that one batch of histopathology reports, which included the affected patient’s, was generated on December 23 by the laboratory but was not received by the ward.
According to the current procedure, a designated printer in the ward automatically prints out reports generated by the laboratory information system. All printed reports are screened by medical staff and filed into patients’ medical records.
The batch of missing reports also included those of two other female patients, whose treatment was not affected. One was diagnosed with teratoma, which was followed up on in January. Another patient had had a miscarriage, and no abnormalities were found in the report.
Concern group Hong Kong Patients’ Voices expressed disappointment at the incident, saying it might indicate “gross negligence” on the part of the doctors involved.