Decision to remove uterus of critically ill new mother was ‘debatable’, panel says, after death at Queen Elizabeth Hospital
Death of woman after heart attack during surgery spurs call to review emergency protocol and training
A decision by a clinical team to remove a critically ill woman’s uterus after childbirth without informing senior doctors – an operation in which she suffered a heart attack – was “debatable”, an investigation panel said on Wednesday.
But the panel, formed to probe the November blunder at Queen Elizabeth Hospital in Yau Ma Tei, failed to pinpoint whether any human error was involved.
It suggested the hospital review and revise its protocol on the emergency management of critically ill patients to ensure timely communication with senior staff and doctors from other disciplines to bring about prompt management and early referral to relevant specialists.
The 33-year-old woman, who was 38 weeks into her pregnancy, was diagnosed with foetal deceleration after bleeding on November 28. Doctors used vacuum extraction to assist the birth, but shortly afterwards the patient experienced post-partum haemorrhage and low blood pressure.
Despite emergency treatment her condition deteriorated, and a doctor subsequently decided to conduct an emergency hysterectomy to avert further severe bleeding.
During the procedure the patient suffered a cardiac arrest, and was transferred to the intensive care unit the next morning, but she died on November 30.
In its report released on Wednesday, the panel, chaired by Dr Cheung Tak-hong of Prince of Wales Hospital, said the clinical team did not involve senior doctors at the department and other specialities early enough.