Inquest jury adopts expert's suggestion

AN inquest jury yesterday recommended that electronic monitoring devices be used to measure oxygen levels of critically ill patients when transporting them between or within hospitals.

The jurors endorsed a recommendation made by expert witness Dr Tony Gin, senior lecturer and honorary consultant anaesthetist at the Chinese University, after returning a verdict of death by misadventure on Filipina Marilyn Ventura, 31.

During the inquest, Dr Gin suggested the continuous monitoring of oxygenation with an oximeter - an instrument for gauging oxygen content in blood - was needed when patients were being transported.

He did not believe medical staff involved in the case were negligent, but he said there had been deficiencies in the care of the deceased.

''They all appear to have acted to the best of their ability in trying to treat the deceased, who was critically ill at the time and required emergency surgery,'' Dr Gin said.

The inquest heard that Ventura died of hypostatic pneumonia, caused by a prolonged coma due to head injuries in October 1991, at Queen Elizabeth Hospital.

Ventura was employed as a maid by businessman Kwan Che-heng.

As the family had a guest on October 10, 1991, she was asked to move temporarily to another house in Fairview Park. On October 14, Ventura failed to appear for work and Mr Kwan went to the house in Fairview Park. He found her lying in a bedroom next to aladder which led to a top bunk.

She was first admitted to Pok Oi Hospital, but was later transferred to Tuen Mun Hospital, where doctors found she had suffered severe head injuries.

Ventura was then taken by helicopter to Queen Elizabeth Hospital for neurosurgery. An endotracheal tube - used to keep the airway open - was inserted through her nose before the transfer.

A doctor who escorted the maid to Queen Elizabeth checked her skin colour and other vital signs and believed the tube was in the correct position.

However, Dr Gin said the human eye was inaccurate in detecting oxygen deficit just by observation of skin colour, and the patient's oxygen levels should have been continuously monitored.

At Queen Elizabeth Hospital, a doctor found the endotracheal tube was in the oesophagus instead of the trachea.

Coroner Mr Warner Banks said doctors gave evidence Ventura was later found to be in cardiac arrest and was resuscitated.

She died six days later.

After the hearing, the executive manager (operations) of the Hospital Authority, Dr Tsui Hing-woon, said a comprehensive overview was needed to assess the demand, feasibility and financial implications of the recommendation.

He said the authority would also look for suitable equipment, adding it should be small, portable and with functions to monitor both oxygenation and vital signs of heart, pulse and respiratory rates and blood pressure.