Hong Kong nurse’s non-standard practice of extubation to blame for death of 83-year-old patient, inquest jury rules
- Jury returns unanimous finding of misadventure in case of retired taxi driver Kay Chee, with medical experts saying they believe the extubation had brought his condition to an ‘irreversible’ state
- Increased manpower, regular training and email reminders on high-risk procedures among eight recommendations to Hospital Authority
A nurse’s non-standard practice of extubation is to blame for the death of an 83-year-old man who had a heart attack after having his catheter removed, a Hong Kong inquest jury has found.
A five-member jury before Coroner Stanley Ho Chun-yiu on Tuesday returned a unanimous finding of misadventure in the case of retired taxi driver Kay Chee, who died of acute myocardial infarction at Queen Mary Hospital on May 30, 2016.
The jury offered eight recommendations to the Hospital Authority, calling for regular training and email reminders on high-risk procedures, as well as an increase in manpower in the intensive care unit, such that medical personnel could be supervised or assisted when performing such tasks.
They also suggested clearer risk assessment forms – to be filled in upon the patient’s admission – and procedures for the authority’s Advanced Incident Reporting System, and recommended that patient relations officers be notified in three days to keep relatives informed.
The coroner said he would pass on these “very appropriate” recommendations to the authority and expressed hope that Kay’s family could move on.
Kay’s son, Stephen Kay Chi-fai, said outside court he was satisfied with the outcome and recommendations, which he believed could address some of the inadequacies in the public health system.