Patient dies at Hong Kong public hospital after ventilation bag not connected to oxygen supply
Incident occurred at Queen Elizabeth Hospital when critically ill man was being transferred to intensive care unit
A patient at a Hong Kong public hospital died after a ventilation bag used during his transfer between wards was not connected to an oxygen cylinder, the Hospital Authority revealed on Monday.
An investigation into the incident at Queen Elizabeth Hospital in Yau Ma Tei was expected to be completed in eight weeks. The patient died on Sunday.
According to a statement by the authority, the patient had chronic illness and was admitted to the hospital last Thursday for severe acute pneumonia. He later developed respiratory failure.
The following morning, staff intubated and connected the patient to a mechanical ventilator to assist his breathing. His condition further deteriorated in the afternoon with septic shock and a continuously declining level of oxygen saturation.
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At about 10pm on Friday, with the patient becoming critically ill, staff transferred him to the intensive care unit. During the transfer, which took two minutes, a self-inflating ventilation bag was used to ventilate the patient manually.
After arriving at the ICU, he was immediately reconnected to a ventilator. The patient developed cardiac arrest five minutes later.
Health care staff later found the ventilation bag was not connected to an oxygen cylinder.
While the patient’s heartbeat resumed after resuscitation, he died on Sunday morning.
Professor David Hui Shu-cheong of Chinese University’s department of medicine and therapeutics said the ventilation bag needed to be connected to an oxygen cylinder, while a medical worker manually pumped oxygen to the patient.
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He said that such a task could be given to a doctor or nurse.
“If you deprive a patient from oxygenation, it will lead to profound lack of oxygen in the blood and injuries to cardiac muscles and conduction system,” he said. Hui added that this would eventually lead to arrhythmia and cardiac arrest.
The hospital has referred the case to the coroner, and a review panel will be formed for thorough investigation to avoid a similar incident.
“The hospital is saddened by the patient’s passing away and expresses its deepest condolences to the family,” the authority’s statement read.
It added the hospital had met the patient’s family again on Monday to explain the incident and apologise. The hospital said it would keep in close contact and provide them with all necessary help.
The authority manages 43 public hospitals and institutions in Hong Kong.
