Hong Kong patient’s death sparks call for better supervision of intern doctors
Coroner records verdict of misadventure on woman, 75, who died following bone marrow procedure
The Coroner’s Court called for better supervision of intern doctors after recording a verdict of misadventure on a 75-year-old woman who died following a bone marrow procedure.
Chan King-chun suffered from internal bleeding and multiple organ failure after the procedure four years ago.
Coroner Ko Wai-hung said if an intern was about to perform a bone marrow aspiration, which involves taking a sample from soft tissue inside the bones, for the first time, an experienced doctor should be there to both demonstrate and supervise.
Supervising doctors should also have “frequently and consistently” performed the procedure for “a certain period”, he said.
“Chan’s case was obviously a misfortune,” Ko said.
“Hospitals indeed have room for improvement.”
The inquest heard Chan was admitted to Pamela Youde Nethersole Eastern Hospital onMarch 25, 2013, after going tothe accident and emergency department with a swollen and bruised left arm.
Chan, who suffered from heart disease and diabetes, was found to have unexplained lower levels of red and white blood cells and platelets.
Doctors decided to perform the procedure on April 19 to find out why.
The first doctor to perform the procedure was an intern who had observed doctors doing so but never carried one out himself.
When he failed to obtain bone marrow after two attempts, the job was taken over by a specialist in infectious diseases, who claimed to haveperformed the procedure50 times in 10 years. Soft tissue wasobtained.
However at least three large blood clots developed and Chan died on May 22 that year from multiple organ failure.
An autopsy found 10 holes close to the lilac crest, a bone in the lower back.
There was also a massive blood clotof 2.5 litres on the left side of the body, which was said to have formed “unnaturally”.
Professor Kwong Yok-lam, a haematology expert from the University of Hong Kong who served as an expert witness, strongly criticised the two doctors, saying they did not know how to perform a bone marrow aspiration.
He described the poor handling of the procedure as “unimaginable”.
Widower Wong Siu-wai, 88, who attended the inquest with his family, said he had been upset for the past four years.
He was now relieved to know the cause of his wife’s death and could collect her death certificate.
Hong Kong Patients’ Voices chairman Alex Lam Chi-yau, a lawyer who represented Chan’s family, said he would urge the Hospital Authority to improve procedures to ensure patients’ safety.
The authority said it would examine the training and guidelines for interns with the two medical schools in the city and further study the recommendations made by the coroner.