A series of blunders by mortuary staff and doctors led to an autopsy being carried out on a 77-year-old woman's body despite a specific request by her family that a post-mortem examination not be performed. The error happened because her body was misidentified through an administrative error.
The woman died of heart failure in Kwong Wah Hospital on Sunday. A day after her death, the coroner accepted the woman's family's request that an autopsy not be performed. But she was subjected to an autopsy by surgeons in Fu Shan Public Mortuary in Sha Tin, medical officials said yesterday.
Staff involved in the latest in a series of blunders at city mortuaries could face legal sanctions and a compensation claim for negligence by her family.
Documents being prepared for the autopsy of a 66-year-old man were stapled by mistake to the forms relating to the woman's case, and a doctor only discovered the mistake after the autopsy. The doctor noticed that the samples taken from the woman's body did not match the case record of the 66-year-old man, and reported this to his supervisor.
Departmental guidelines require that staff at each level should check the identity of a body against the autopsy order issued by the coroner, and the order should have been placed on top of the body for easy reference by staff.
Explaining the blunder yesterday, Assistant Director of Health Dr Heston Kwong Kwok-wai said as the case was still under investigation, it was unclear whether each of staff involved had referred to the coroner's order.
'Some essential and critical steps had not been fully complied with in this unfortunate event,' he said.
Kwong, along with Acting Consultant Forensic Pathologist Dr Poon Wai-ming, apologised four times and offered condolences to the woman's family.
Kwong said they reported the incident immediately to the family concerned, who demanded a written reply within a week. The family also asked to see the body again to confirm her identity.
A full report on the incident will be released in two weeks, Kwong added.
He said the incident was not caused by manpower shortages, and that the department had immediately instructed all staff to strictly follow the guidelines.
'It is a very rare case and has never happened before. We believe that by reminding staff of the guidelines, the service quality can be immediately improved,' he said.
He added that the senior doctor who performed the autopsy had been moved to a position that did not require him to do post mortem examinations.
Kwong said in the wake of the incident, a doctor-in-charge system has been introduced across all the three public mortuaries in the city.
He added that the three mortuaries - Fu Shan, Victoria and Kwai Chung - were all undergoing ISO accreditation processes to certify management standards.
Alliance for Patients' Mutual Help Organisations vice-chairman Cheung Tak-hai said the blunder was 'outrageous'. He said even though the staff involved might eventually receive a 'minimal penalty', it would only come months later via the civil service bureaucracy.