A Hong Kong surgeon who operated on the wrong organ of an elderly patient had shown “confirmation bias” in identifying structures in the abdominal cavity, an investigation into the blunder has found, prompting a former lawmaker to call for his dismissal.
Tseung Kwan O Hospital on Thursday released a cause analysis report on the February 7 incident involving an 85-year-old woman with obstructive sigmoid colon cancer and who died three weeks after the operation.
She had undergone what was intended to be a transverse colostomy to relieve an intestinal blockage, a procedure that involves creating a surgical opening in the abdomen, known as a stoma.
Although her vital signs remained stable, doctors noted unusually high stomal output.
On March 1, she developed low blood pressure and an increased heart rate and was transferred back to Tseung Kwan O Hospital from Haven of Hope Hospital the following day.
A CAT scan showed that the stoma had been created in the stomach rather than the colon.
Her condition deteriorated and she died on March 3 after her family agreed to a do-not-attempt-resuscitation order.
The public hospital disclosed the incident in March following media inquiries, adding that it had launched an investigation and referred the case to the Coroner’s Court.
The report identified multiple deficiencies among the medical personnel involved in the operation.
“The surgeon exhibited confirmation bias when identifying abdominal cavity structures, wrongly exteriorised the stomach instead of the transverse colon during the surgery, without performing additional confirmation measures,” the hospital said.
The report also cited inadequate monitoring of abnormal stomal output, insufficient experience among healthcare staff, and poor communication between surgical and rehabilitation teams, which delayed reassessment and intervention.
Former lawmaker Michael Tien Puk-sun said the doctor in question had a history of errors and urged authorities to consider demotion or, ultimately, termination of employment.
“The investigation findings were unbearable, and the authority says it will make improvements all the time following blunders. When will we really see improvement?” he said. “The latest blunder is a rookie mistake, which damaged Hong Kong’s brand as a medical service hub.”
The panel made several recommendations, including reviewing clinical governance in the surgery department, ensuring surgical team involvement after patient transfer, and requiring stoma and wound care specialists to assess post-operative patients with proper documentation and timely reporting.
Tseung Kwan O Hospital said it had accepted the recommendations and had already implemented measures to enhance patient safety, including restructuring the department of surgery under a cluster-based governance model.
The hospital added that it would follow up with the doctors involved under human resources procedures and might refer the case to the Medical Council. -- SOUTH CHINA MORNING POST
