Poor communication between clinical teams led to fatal mix-up in Hong Kong public hospital, investigation concludes
- A 60-year-old patient died from bleeding after a liver biopsy when coagulant injections were not halted
- The investigating panel recommended enhancing patient safety by strengthening communication between teams
Inadequate communication between clinical teams resulted in the death of a 60-year-old patient who bled heavily and died in a public hospital after a procedure to extract liver tissue, an investigation panel has concluded.
The panel was set up by Princess Margaret Hospital to investigate the death of the man, who was diagnosed with necrotising pneumonia due to community-associated methicillin-resistant Staphylococcus aureus (MRSA), and was admitted to its intensive care unit last November.
He was prescribed daily injections of anticoagulants since January 3 after computed tomography (CT) scanning showed that he had deep-vein thrombosis – the formation of a blood clot in a deep vein.
He was given the medication at 3pm on January 9 as scheduled, but a doctor performed a liver biopsy to investigate the cause of liver enzyme derangement two hours later.
In a statement released on Friday, the hospital said the patient developed haemorrhagic shock following bleeding from the liver later that evening.