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https://scmp.com/news/hong-kong/health-environment/article/2093701/united-christian-hospital-failed-inform-liver Health & Environment
Panels to investigate if Hong Kong hospital and doctors covered up liver patient blunder
Two specialists ignored automatic computer alert when giving the woman harmful dose of steroids
Hospital Authority chief executive Dr Leung Pak-yin said he did not think there had been a deliberate attempt to conceal what happened. Photo: Felix Wong
Two investigation panels will probe whether a Hong Kong public hospital and two doctors deliberately covered up a serious medical blunder that left a woman dying and desperate for a liver transplant.
It emerged on Tuesday that two specialists at United Christian Hospital made the error despite an automatic reminder in the computer system that warned them of the risk of kidney patient Tang Kwai-sze suffering acute liver failure if they gave her a high dose of steroids.
Both doctors ignored the alert and did not prescribe Tang, who suffered from hepatitis B, a drug to prevent the potentially fatal side-effects when they treated her in January and February, according to Hospital Authority chief executive Dr Leung Pak-yin on Wednesday.
Michelle (in mask), the daughter of patient Tang Kwai-sze, said the family was never informed about the mistake until they questioned the hospital about her mother’s sudden liver condition. Photo: Felix Wong
A Queen Mary doctor also broke his silence to reveal that United, which had already discovered the oversight on April 5, had failed to inform them of the blunder. United kept Tang’s family in the dark until her teenage daughter, Michelle, demanded an explanation for her sudden liver condition on April 19.
The hospital also did not report the mishap to the Authority until April 20, violating the protocol of flagging serious incidents within 24 hours, Leung said.
Dr Kelvin Ng Kwok-chai (left) and colleagues meet the media at Queen Mary Hospital’s Liver Transplant Centre last month. Photo: David Wong
“I do not believe there was a mass cover-up done by anyone intentionally in the Hospital Authority. The investigative panels will look into it.”
Health minister Dr Ko Wing-man promised the investigations would be “independent and accountable”.
Leung said it was still unclear why the two doctors had neglected the risk even when the computer system had a pop-up window to remind them of the correct procedure. He would not rule out negligence due to excessive workloads placed on doctors.
Leung explained that the Authority did not make the blunder public until Tuesday, over two weeks after it had been notified, as it had been waiting for one of the two doctors “to return from holiday” on May 7.
A new independent panel formed on Wednesday will review the current reporting system, especially the timeliness of public disclosures. Another panel has already been set up and is due to submit its report in eight weeks.
“This is absolutely a serious medical accident,” said Dr Kelvin Ng Kwok-chai, who works at Queen Mary’s liver transplant centre.
He had not been informed of the blunder by United and found out only when he looked at medical records in the computer system, after which he informed Tang’s family.
“Like Michelle, I was shocked when I found out about this,” he said.
Michelle (right) made a public appeal to save her mother, Tang Kwai-sze (left). Photo: Handout
The case drew widespread attention across the city after Michelle made a public appeal on her mother’s behalf. The teenager was unable to donate part of her own liver to save her mother as she was three months shy of the legal age of 18. Her relatives had considered legal action to get approval for the donation.
A stranger, Momo Cheng Hoi-yan, 26, came to the rescue and donated two-thirds of her liver. But the new organ did not function well and about a week later Tang received a second transplant, this time from a deceased donor.
July 2016: Tang Kwai-sze is diagnosed with IgA nephropathy – a kidney disease that occurs due to an accumulation of an antibody – in United Christian Hospital
January 20: A doctor at the specialist outpatient clinic prescribes high dosage of steroids to Tang but fails to give her an antiviral drug, without which, as a hepatitis B sufferer, she will face the risk of liver failure
February 17: Tang sees another United Christian doctor, who reduces the dosage but still does not give her the antiviral drug
April 1: Tang is admitted to the hospital’s emergency department with signs of bleeding and jaundice
April 5: Tang is moved to Queen Mary Hospital’s liver transplant centre and put on a waiting list for an organ donation
April 6: United Christian reviews her medical records and discovers the previous doctors’ oversight
April 12: Daughter Michelle, 17, pleads to be allowed to take a donor test to help save her mother’s life. But she is three months shy of 18, Hong Kong’s legal age for living donors
April 13: Momo Cheng, a 26-year-old clerk, donates two-thirds of her liver. Government promises to review the organ donor law
April 19: Tang’s family approach United Christian for medical records and are told what has happened
April 20: United Christian reports the incident to the Hospital Authority’s head office. At the same time, Tang receives a second organ from a deceased donor after the first liver fails to function properly
April 21: Hospital chiefs meet Tang’s family to make an apology for the blunder
April 29: Michelle’s plight encourages hundreds of Hongkongers to sign the organ donor register
May 6: Medical teams fight to save Tang’s life after she contracts a serious infection
May 9: United Christian admits the blunder
May 10: Tang remains in critical condition, relying on artificial lungs and dialysis to stay alive