Medical blunders led to death: coroner

A coroner criticised hospital staff yesterday after ruling that two medical blunders committed within hours of each other led to the death of a 67-year-old woman.

Man Chuen-tai was admitted to North District Hospital on September 7 last year after suffering from severe abdominal pain. She was diagnosed as having a bile duct infection and underwent an operation at about 2.30pm on September 9.

Dr Leung Kam-fung, one of the two doctors performing the operation, later found that her duodenum - the first section of the small intestine - had burst. The doctor, who had performed more than 230 such operations, told the inquest he was not sure what caused the rupture.

Recording a verdict of death by misadventure, Coroner Andrew Chan Hing-wai said: 'While the cause may remain unknown, there is no doubt the duodenum was injured during the operation. This first blunder spelt the beginning of a string of misfortunes and [Man's] death.'

Man was then transferred to the intensive care unit (ICU) where surgeons sought to drain air from her chest cavity.

ICU doctor Lam Wai-kei told the inquest the procedure was conducted three times and thick blood was drained out.

Mr Chan said: 'In view of the autopsy finding that the deceased died from haemorrhage due to a burst blood vessel near the lung, I rule that it was when the tube was inserted the first time that the vessel burst. This was the second blunder.'