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Ng Kang-chung

A Hong Kong patient died after suffering a heart attack when he was fed a regular meal instead of the required soft food and choked at Prince of Wales Hospital.
The public hospital in Sha Tin issued a public apology on Friday and said it had appointed an eight-person panel to look into the blunder.
A report, along with recommendations for improvement measures, is expected in eight weeks.
The 54-year-old male patient was admitted to hospital on Wednesday morning “due to deteriorated mental status”, the Hospital Authority said in a statement reporting the sentinel event.
The man had no identification document upon admission, so the hospital generated a “pseudo identifier” for registration.
Given his clinical condition, the attending doctor subsequently gave a “diet as tolerated”, or DAT, order for nursing staff.
DAT generally refers to a medical instruction indicating that a patient should consume food and fluids according to his or her individual tolerance and comfort level.
But the hospital’s catering management system defaults to arranging a regular meal for patients registered under a pseudo identifier.
“A nursing staff member did not complete checking the patient’s previous diet records to adjust the diet order, [and] a regular meal was served to the patient that night,” the hospital said.
He started feeling unwell while fed by a patient care assistant.
Doctors were called to help remove the obstruction in the patient’s airway, but during the emergency treatment, he went into cardiac arrest.
His condition continued to deteriorate, and he died late that night.
“Upon reviewing the patient’s history after the incident, the hospital found that the patient had been frequently hospitalised before due to underlying diseases,” the authority said.
The patient was said to have suffered from dementia and had a history of stroke.
“Following speech therapy assessment, a purée diet was recommended for the patient due to dysphagia,” it said, referring to difficulty swallowing.
The hospital said it was deeply saddened by the death and had met with the patient’s family to explain the incident, extending its sincere apologies and condolences.
“The hospital has devised immediate measures, including reminding healthcare staff to thoroughly assess patients’ clinical conditions and diet orders before making meal arrangements and reviewing the default meal setting of the [dietary and catering management] system,” it said.
“The nursing staff member and [patient care assistant] concerned have been temporarily arranged for non-clinical duties.”
A similar blunder was reported at Caritas Medical Centre in March last year when a 75-year-old patient choked to death after a nurse misunderstood the doctor’s instructions due to a communication error and gave him the wrong food.
The man, who was supposed to be on a puréed diet, was fed solid food instead.


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Prince of Wales Hospital says man, 54, lacked identification and was given temporary identity, which contributed to wrong food order


Prince of Wales Hospital says man, 54, lacked identification and was given temporary identity, which contributed to wrong food order.


Prince of Wales Hospital

Hospital Authority

Sha Tin

Caritas Medical Centre

Patient who needed soft food dies after choking on regular meal at public hospital

.css-1c6uqr6{color:inherit;font-weight:inherit;font-size:inherit;font-family:inherit;line-height:inherit;overflow-wrap:break-word;}Prince of Wales Hospital says man, 54, lacked identification and was given temporary identity, which contributed to wrong food order

Prince of Wales Hospital says man, 54, lacked identification and was given temporary identity, which contributed to wrong food order