Hong Kong court calls for alert system to deal with urgent patient treatment in wake of man’s death
The case related to a leukaemia sufferer who went to Princess Margaret Hospital but was denied treatment for five hours; he died three days later
The Coroner’s Court on Tuesday called on Princess Margaret Hospital to establish an electronic alert system to repeatedly inform healthcare workers about the urgency of treatment for patients in the wake of a leukaemia sufferer’s death. It also said the system should specify what treatment was needed.
The recommendation came from a five-member jury, which found that Lin Sui-man, 46, died of an accident due to a brain haemorrhage on May 12, 2014.
The victim was not given any treatment, including a blood test, for five hours after he went to the hospital in Kwai Chung.
The jury was told that the hospital had failed to schedule a follow-up appointment for Lin for a critical blood test on May 7 to monitor his blood platelet level, as his doctor had requested.
The court also heard that Lin went to the hospital’s emergency unit at 3am on May 9 with a card indicating he had priority, but had to wait for tests.
A brain scan carried out at 8.12am revealed he was suffering from internal bleeding and a sample of blood taken at 8.56am showed his blood platelet level had dropped to just one. The normal count is from 150 to 450.
He soon fell into a coma and died three days later, He was survived by his wife, Huang Huizhan, and three children.
Huang cried as she thanked the court for investigating her late husband’s death. But she added outside court: “I feel very sad, the court ruling cannot return my husband to me.”
Coroner Ada Yim Shun-yee said she hoped similar deaths could be avoided as the present case showed its grave impact on a family.
“The court can see you had to care for your children while mourning your husband,” she told Huang. “The court offers its deepest condolences.”
In a statement, the Hospital Authority apologised for what had happened and pledged to follow up on the jury’s recommendations on top of the improvement measures rolled out since Lin’s death.
It said the hospital had since May 2014 tagged high-risk patients in the medical record system to alert other healthcare workers that prompt treatment was needed and reinforced their understanding, alertness and responsiveness in handling high-risk patients.
The hospital also enhanced its blood collection service and clinical training for staff to deal with rapid drops in platelet counts, and introduced pre-admission blood taking in accident and emergency units for patients in need.
Professor Kwong Yok-lam, a haematology and oncology specialist, had previously criticised the hospital for its lack of vigilance over patients with low-blood-platelet levels who might be suffering from the side effects of chemotherapy.
He testified that “a lot of things could have been done” as it was illogical for hospital staff to be unaware of Lin’s low platelet count, given his past medical record.
He recommended a more effective system to help the hospital identify those suffering from blood platelet issues as well as training to help improve the ability of staff to prioritise cases based on urgency.
The jury also suggested that doctors should help schedule their patients’ appointments, but that recommendation was withdrawn after the coroner reminded them of the heavy workload faced by medics.
The court heard the hospital had introduced an additional round of checks by senior nurses to ensure that doctors’ instructions on appointments were followed.