Hong Kong radiographer ‘relied on patient’s verbal cues’, in blunder over rectal device inserted into woman’s vagina
Queen Elizabeth Hospital releases panel findings on July case, with woman’s family lodging complaint and calling for staff’s ‘severe punishment’
An investigation panel confirmed on Friday that a Hong Kong radiographer had failed to conduct proper checks and relied on verbal cues from the patient when he wrongly inserted a rectal medical device into her vagina.
The findings released by Queen Elizabeth Hospital came after reports in July of the medical blunder, in which the 79-year-old woman’s reproductive organ was damaged and her Fallopian tubes removed to prevent infection.
On Friday, investigation results described the incident as “rare” based on medical literature.
The patient’s family, who met hospital representatives and released a statement on the same day, expressed anger at the staff member involved and said they had lodged a complaint with the Supplementary Medical Professions Council.
The council is responsible for the registration and discipline of people in five professions in the sector, including radiographers.
The case happened on July 4, when the woman, who suffers from chronic illness, underwent a barium enema examination – a procedure in which contrast liquid is introduced into the colon to detect abnormalities.
An enema tip, the device used for the procedure, was intended for rectal insertion, but wrongly placed into the patient’s vagina.
The radiographer – a man, according to a source – did not check the position for insertion and relied only on verbal confirmation from the patient that the device was in her anus. A balloon-like part attached to the enema tip was then inflated once the device was introduced, to avoid leakage of the contrast liquid.
Staff suspected something was wrong when X-ray images showed barium in the patient’s pelvis.
It was then that the radiographer was asked to check the position of the enema tip. He discovered it had been wrongly inserted into the woman’s vagina.
The hospital said the woman made a “satisfactory recovery” and was discharged on July 24.
The investigation panel, headed by radiologist Dr Danny Cho Hing-yan, concluded that the radiographer “did not see clearly the patient’s perineum” when inserting the enema tip.
It also said “a visual check was not performed after insertion”.
In addition, the inflated balloon of the enema tip also caused injuries to the vagina and forced the barium into the woman’s uterine cavity and her fallopian tubes.
The panel recommended the hospital and the Hospital Authority revise the workflow of the barium enema examination, such as having another radiographer or a radiologist reconfirm the positioning of the device after insertion.
Also, before inflating the balloon, a doctor had to confirm again that the device was correctly positioned.
The hospital said it had explained the investigation results to the patient’s family and issued another apology.
In their statement, the family requested the authority to “severely punish” the radiographer.