The Eastern Hospital body blunder came just days after 56-year-old logistics company owner Yeung Tak-cheung died from a heart attack, despite collapsing just outside the Caritas Medical Centre in Cheung Sha Wan.

The incidents happened during a year of relative calm for the blunder-plagued authority, which was set up in 1992 under a landmark management reform of the then Medical and Health Department.

After the body blunder, Secretary for Food and Health York Chow Yat-ngok ordered the authority to deal with 'irresponsible staff' at mortuaries once and for all.

'I will personally ensure that the Hospital Authority and the mortuary management of other public mortuaries will learn from this particular incident to ensure that nothing like this will happen again,' Dr Chow told the Legislative Council.

The authority has conducted a preliminary investigation into the incident, and will report its findings to the Legislative Council on Monday. It will also announce details of reforms aimed at preventing further mix-ups at the mortuaries.

The baby boy was born at 35 weeks, on December 15, weighing just 1.1kg. He was baptised and died soon after.

After his death, 'Baby K' - whose name has not been released nor those of his parents - was placed in a body bag and put in a special compartment designated for deceased babies or large adults in the hospital's mortuary.

According to the authority's report, on December 17, a large adult body was put in the same compartment with the baby's body. The man's body was released to his family on December 19.

It was not until a routine counting of bodies on January 2 that it was discovered that the baby was missing. Three days later, on January 5, the hospital's management was informed, along with police and the Hospital Authority. The parents were informed on January 6, the same day the authority announced the blunder.

The authority's chief executive, Shane Solomon, said: 'The HA regrets the incident and would like to express the deepest apology and condolences to the family of the baby. Full support will be rendered to the family.'

Hong Kong East Cluster chief executive Loretta Yam Yin-chun, who is also the hospital's chief executive, said the hospital had no idea where the body was and blamed the loss on negligence. 'Our staff's reaction was slow, they were not alert enough, and when they found out a body was missing, they started their own investigation but did not report it to their superiors,' she said.

One of three hospital mortuary attendants has been suspended and one technician has received a warning. The hospital said there was no reason for the worker to place the baby's body in the same compartment as the adult, because vacant compartments were available.

But how could the incident have occurred, despite Hong Kong having 'the world's best mortuary system', in the words of Dr Chow?

The city's mortuaries - run by either the Hospital Authority or the Department of Health - underwent a major overhaul after a spate of widely reported body mix-ups which began on March 7, 2006, with the case of Wong Fong-ho, 90, who was wrongly cremated at Fu Shan Public Mortuary. His remains were mixed up with those of a 57-year-old man.

Mortuary workers' attitudes had been in the spotlight amid revelations that mortuaries were so crowded, bodies were often piled up and workers had to step on them. The overcrowding was eased by the opening of a fourth mortuary in late 2005.

Yet, with the latest incident, the authority has now realised that despite an improved system for handling corpses, there are no standardised practices among hospitals, a senior authority source told the South China Morning Post.

That lack of specific guidelines was also one of the factors that led to the death of heart attack victim Yeung, according to the hospital's investigation report released last week.

Until that incident, the Hospital Authority did not have guidelines for responding to medical emergencies right outside hospitals.

Mechanisms for responding to medical emergencies near hospitals existed in 'some hospitals, but not all', Leung Pak-yin, the authority's director for quality and safety, said when the Caritas report was released.

'There are inconsistencies here about the principles and guidelines,' Dr Leung said. 'What we are doing is issuing general principles in terms of requests for help from the general public, even outside hospitals.'

New guidelines, a one-page document entitled, 'General principles for handling emergency cases in the vicinity of HA hospitals and clinics', now underscore that 'saving people's lives is the authority's first priority'.

All staff on duty will 'render all reasonable assistance ... to anyone who requires emergency medical assistance at any time'.

Mr Solomon said: 'We just assumed they would respond [to medical emergencies outside hospitals] with common sense, making the guidelines unnecessary.

'Guidelines are a way of eliminating any doubt as to whether we have the responsibility to respond.

'Also, it became obvious when we looked around, there were some inconsistencies between hospitals, so we were not aware of this until this incident.'

The hospital will also take other measures, including making portable defibrillators available on the premises.

The hospital's report was released last Monday. The hospital's chief executive of six months, Ma Hok-cheung, who prepared the report - admitting glaring gaps on several fronts - refused to resign.

Kwok Ka-ki, former legislator for the medical sector, said it was time the Hospital Authority accepted long-standing recommendations for major structural reforms from at least two expert reports - one on health care reforms and the other prepared after the Sars crisis.

Dr Kwok, who is launching a new 'Caring Hong Kong' think-tank, said: 'I think all the blunders actually point to one basic issue: the governance of the Hospital Authority.'

The authority's all-too-powerful board should set out a vision for the body and its chief executive should execute it, he said. He also questioned the governing committees at each hospital, which he said should oversee each hospital but were not functioning properly in that role.

The board is chaired by Anthony Wu Ting-yuk, who is chairman of the pro-government Bauhinia Foundation Research Centre and has served as a National Committee member of the Chinese People's Political Consultative Conference since 1998.

Mr Solomon is the first non-doctor to head the heavily subsidised authority, which has an annual budget of HK$30 billion. The former executive director of public health and aged-care services in Victoria, Australia, took up his post on March 1, 2006, at an annual salary of HK$4.1 million.

'We used [that much money] to hire a new chief executive hoping to change the authority, yet the board is not helping him to do the reforms,' said Dr Kwok, who believes the buck should stop with Dr Chow, as he appoints the board members.

'If the HA structure stays with the present model, I think blunders will never end. Blunders cannot be avoided totally, we all agree, because we are in an industry that is affected by the performance of staff and professionals. But we do not expect them to occur again and again in the same section, for example in mortuaries.'