A retiree sent to a Hong Kong hospital for treatment of chronic lung disease died of natural causes, but should not have been left unattended for hours in the accident and emergency department lobby, the Coroner’s Court has ruled.
Coroner Arthur Lam Hei-wei said in his verdict on Monday that the incident “should not have happened” if Lai Yeuk-chung had not been left unattended for more than six hours at Kwong Wah Hospital in Yau Ma Tei on February 26, 2021.
Lam, speaking at the end of a four-day hearing at West Kowloon Court, expressed his condolences to the widow and two children of Lai, who died at the age of 63.
But the coroner added that it was not within the remit of the inquest to take to task any specific individual for the death of the retired construction worker.
He could only “make suggestions” to the Hospital Authority in the hope that such incidents would not happen again.
Addressing Lai’s family directly, Lam said the inquest’s findings “might not reduce your pain, but I believe the Hospital Authority will follow up on my suggestions”.
Lam called on the authority to ramp up efforts to set up a mechanism in hospitals that ensured patients waiting to be transferred from emergency rooms to wards could be located and tracked.
He also asked the authority to implement a better system of allocating medical staff for finding and moving patients.
During the inquest, the court heard that staff in the Kwong Wah Hospital A&E department had called out Lai’s name three times between 10.30pm and 11.50pm on February 26, 2021, in their attempts to locate him.
Lai had been brought into the A&E department earlier that afternoon after experiencing shortness of breath and coughing up blood.
CCTV installed in the hospital showed that Lai, lying on a trolley bed, had gripped its rail and attempted to move. He was only found by medical staff at around 5am the next day. By then he was unconscious and subsequently pronounced dead.
A specialist of respiratory and internal medicine said Lai had previously been diagnosed with chronic obstructive pulmonary disease, a lung disease causing restricted airflow and breathing problems.
Lai’s condition had deteriorated and he had experienced an acute worsening of symptoms while waiting unattended in the lobby of the A&E department.
Coroner Lam quoted the specialist as saying “appropriate treatment” had been arranged for Lai in the ward. However, medical assistants had not been able to locate the patient in the A&E department and send him on to be treated.
“This manual way of locating patients is not comprehensive,” Lam said.
He concluded that the cause of Lai’s death was acute exacerbation of chronic obstructive pulmonary disease.
The authority last April announced a series of measures aimed at enhancing patient safety, including an hourly inspection of toilets in A&E departments and patrols of patient waiting halls.
The move was made not long after a 58-year-old chronically ill woman was found unconscious in a toilet for disabled people at Pamela Youde Nethersole Eastern Hospital and later certified dead. She had waited for more than 12 hours in the hospital’s emergency department.
Secretary for Health Lo Chung-mau at that time said a coroner’s inquest would follow after the investigation into the woman’s death.
The Hospital Authority said it respected the coroner’s verdict and would study his suggestions. It said a committee set up to review the incident had improved operations at A&E departments, including marking a waiting area for patients in the redevelopment plan for Kwong Wah Hospital.
“The authority has gradually introduced patient-tracking systems in 18 public hospitals to monitor high-risk patients. Patients who consent to be given a tracking device after registration would be tracked on the system that shows their location in the emergency room,” it said.
It added that new technology had enabled the staff, who were well-trained, to systemically monitor patients waiting to be transferred from the department to wards.
