“The panel considers the three-hour halt of the operation unnecessary and could have been prevented.”

Tong added the panel concluded the incident was not related to manpower, which he described as “similar to the levels of the past few years”.

Tong said Ng arranged the operation at the private hospital on September 27. In late September, Ng was notified of his October duty roster in Queen Mary. But Tong did not specify whether Ng arranged the other operation before or after knowing his duty arrangement.

“As a part-time staff member, Ng had his own scheduled operations at private hospitals and he was not required to inform us,” Tong said.

The panel also revealed that Dr Tiffany Wong Cho-lam, the surgeon whom Ng supervised during the transplant in question, decided to wait for Ng to resume the operation because of safety concerns.

“Dr Ng told Dr Wong that she could continue the surgery under normal circumstances,” Tong explained. “But there were some special conditions concerning the donated liver, and Wong decided it was not appropriate for her to conduct the operation alone.”

Tong did not elaborate on the “special conditions” of the liver, citing donor privacy.

He said Wong had also tried to seek help from other doctors, but they were either on leave or involved in other operations.

The panel said Ng exercised incorrect judgment in thinking Wong could complete the operation alone, and did not discuss a contingency arrangement with her in advance.

Hong Kong health minister voices grave concern over liver patient stranded without surgeon for three hours

Queen Mary Hospital chief executive Dr Luk Che-chung said separate procedures would be followed to determine whether Ng would be punished.

“Punishment laid by the Hospital Authority could range from issuance of a warning to termination of honorary appointment.”

Luk noted the incident had prompted the hospital to be more explicit about its expectations for such staff.

“We will be more detailed in stating clearly a job role when appointing honorary staff,” he said. “Better communication could reduce the chance of different interpretations.”

The panel suggested the hospital should issue a code to regulate the roles and responsibilities of honorary staff. The hospital should also emphasise that if a doctor were put on the call list, he or she should act timely in responding to patients’ needs.

As Ng was hired by HKU as a part-time staff member, the institution said a mechanism looking into personnel arrangement had been activated to handle Ng’s case.

Patients’ Rights Association agreed with the investigation finding and hoped it served as a warning.

“It is quite rare to see the investigation panel using a harsh term such as ‘unacceptable’ to describe Dr Ng’s conduct,” spokesman Tim Pang Hung-cheong said.

“I believe using this term is appropriate.”

Pang believed the report proved that Wong had exercised correct judgement in waiting for him and should not be blamed as she had acted out of concern for the patient’s safety.

Professor Lo Chung-mau, director of the hospital’s liver transplant centre, said Ng could have prevented the incident from happening through better communication or rescheduling his other commitment.

Additional reporting by Emily Tsang