Mother’s death after drug prescription blunder ruled misadventure by jury

A five-strong jury ruled on Tuesday by a 4-1 vote that the death of the 44-year-old mother of two Tang Kwai-sze, who died after a drug prescription blunder seven years ago, was due to misadventure.

Tang was diagnosed with kidney disease in 2016 at United Christian Hospital. However, she experienced acute liver failure and subsequently received a liver transplant as a result of a missed prescription. She eventually passed away at Queen Mary Hospital on August 26, 2017.

The inquest earlier revealed that doctors Lam Chi-kwan and Chan Siu-kim from United Christian Hospital failed to prescribe anti-hepatitis B viral drugs to Tang during her kidney treatment between August 2016 and February 2017 despite Tang having been a carrier of the disease since 2008.

Coroner Monica Chow Wai-choo said before the verdict that, after the drug prescription blunder in 2017, the Hospital Authority (HA) has implemented several improvement measures and rolled out new policies to check patients’ baseline of the hepatitis B virus before treating them with steroids.

The HA has also amended the drug registry so that high-risk hepatitis B patients can receive a subsidy and purchase antiviral drugs at the standard price.

The coroner further referred to the testimony of an expert which claimed the risk of having an episode of hepatitis B would increase when consuming a high dose of steroids within a short period of time. Yet, the HA currently doesn’t categorize patients receiving treatment of less than seven days in the high-risk group.

The jurors retired for deliberation around 10 am on Tuesday after being guided by Chow yesterday to determine whether Tang’s death was caused by misadventure, natural causes, or to deliver an open verdict.

After about seven hours of discussion, the jurors concluded that Tang had died of misadventure with a 4-1 vote as the hepatitis B virus was activated due to the administration of a high dose of steroids without antiviral medication.

They suggested that doctors have to prescript the antiviral drugs for the patients who receive high doses of steroids though the treatment is less than seven days.

The jurors also urged HA to ensure that asymptomatic hepatitis B patients can purchase antiviral drugs at the standard price.