A 75-year-old male patient at Caritas Medical Centre choked to death after being given the wrong food by health personnel due to a suspected communication error.
Cluster Chief Executive of Kowloon West Alexander Law Chun-bon said a male elderly patient choked while having lunch at Caritas Medical Centre on March 3. Despite the medical staff’s efforts to save him, the patient could not be rescued and died on the same day at around 1.30pm.
Law described the incident as "deeply unfortunate" and expressed his apologies to the family, noting that it appears to have stemmed from a communication error.
Hospital Chief Executive of Caritas Medical Centre Gladys Kwan Wai-man stated that the patient was admitted on February 28 for abdominal bloating and he had a history of hypertension and cognitive impairment and was on a pureed diet.
She noted that the patient was initially on a fasting regimen upon admission. After his condition improved, the doctors in charge wrote “DAT” in the patient’s medical records, which stands for “diet as tolerated,” indicating that the patient could resume his usual diet -- a pureed diet.
However, a fifth-year nursing student misunderstood this to mean the patient could consume regular meals that contained solid foods and proceeded to feed him accordingly.
Kwan said that the nursing student was feeding the patient bite by bite to ensure he could swallow properly, but later found he was choked and immediate resuscitation efforts were initiated.
During intubation, the emergency team found food remnants in his throat. Despite efforts to clear the obstruction, resuscitation was ultimately unsuccessful, and the patient passed away on March 3.
Kwan noted that the feeding instructions were issued by a colleague of the nurse in charge, who had four years of experience, and the nursing student was following those instructions.
At the time, the nursing student was solely responsible for feeding the patient who choked, with a supporting nursing team present in the ward.
The medical staff involved are currently on leave. The case will be referred to the Coroner’s Court, and Kwan noted that whether the involved staff will face criminal prosecution depends on the investigation’s findings.
“All our colleagues are very saddened. We will assess the situation again this week to determine the duration of their leave,” she said.
It is understood that normally, meal distribution is managed by the ward nurse, who directs which patient receives what kinds of meals.
The ward assistant then delivers the meal to the patient’s table, and it is fed to the patient by the nurse or nursing student, who does not conduct a re-check.
“Every link is interconnected; any issue that arises is often the result of small mistakes evolving into larger ones,” Kwan said.
The incident follows a medical blunder in 2023, which resulted in the death of a 79-year-old eye patient due to staff negligence in failing to turn on the oxygen valve.
The hospital has pledged to enhance training and clarify roles for healthcare personnel last year.
Meanwhile, family doctor and former emergency physician Lee Fook-kay noted that patients with cognitive disorders are more susceptible to choking on food due to weakened neural reflexes.
“Typically, when a healthy person chokes on food, their throat has a neural reflex that helps expel the object, while those with cognitive decline have diminished reflexes, the likelihood of food entering the airway will be increased,” Lee explained.
Regarding the use of “DAT” to indicate resuming food intake, Chairman of the Association of Hong Kong Nursing Staff Tse Kin-keung confirmed that it is a common practice.
“This means that patients can eat whatever they can tolerate. However, if a patient has diabetes or kidney disease, their dietary needs must be adjusted accordingly,” he explained.
“For those with swallowing difficulties, meals may need to be thickened as advised by a speech therapist to prevent choking,” Tse noted.
(Cheng Wong)
