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

PUBLISHED : Wednesday, 25 January, 2017, 11:09pm
UPDATED : Thursday, 26 January, 2017, 11:57am

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.

“The patient was critically ill when arriving at the operating theatre. It was debatable whether one should have proceeded with the planned hysterectomy or the patient sent to the ICU to support the heart and lungs functioning, given that the vaginal bleeding continued,” the report said.

“It was even more debatable whether the hysterectomy was an appropriate decision when the patient developed cardiac arrest.”

However, the panel was of the view the patient’s outcome might not have been any different irrespective of medical treatment in light of the severity and rapidly deteriorating nature of her condition.

The panel called on the hospital to enhance staff training in identifying and managing critically ill patients and conduct regular drills with debriefings to share incidents with staff of related departments, including gynaecology, the ICU and anaesthesia, to facilitate multidisciplinary management of critically ill patients.

“The medical teams concerned have been receiving simulation training since December last year to enhance their preparedness in management of post-partum haemorrhage and other medical emergencies,” the hospital’s chief executive, Dr Albert Lo, said.

Hospital Authority chief executive Dr Leung Pak-yin said the human resources office would separately follow up on whether there had been any professional misconduct by the staff involved in the incident.

He said more evidence, including follow-up from the Coroner’s Court, would be needed to determine whether there had been any misconduct.

Leung said the report showed that support from other departments may have been delayed when handling acute patients.

“We will enhance communication between different units and departments ... Hospitals under the Hospital Authority will also review their practices and aim to [keep] medical blunders [to a] minimum,” Leung said.

Additional reporting by Elizabeth Cheung