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Tseung Kwan O Hospital announced on Thursday the findings of a root cause analysis report into a sentinel event in which an 85-year-old female patient died after a surgeon mistakenly exteriorised her stomach instead of her transverse colon during a stoma procedure.
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The patient underwent a transverse colostomy on February 7 to relieve intestinal obstruction caused by sigmoid colon cancer. She was later transferred to Haven of Hope Hospital for rehabilitation on February 16. On March 1, she developed hypotension and tachycardia and was transferred back to Tseung Kwan O Hospital. A CT scan revealed the stoma was located at the stomach. Her condition deteriorated and she died on March 3 after a family decision not to attempt cardiopulmonary resuscitation.
The RCA Panel concluded the surgeon exhibited confirmation bias when identifying abdominal cavity structures, wrongly exteriorising the stomach without additional confirmation measures. It also found that healthcare staff did not recognise an increasing trend in stomal output before the patient's transfer, and that rehabilitation staff lacked relevant experience in managing post-stoma patients. Inadequate communication between surgical and rehabilitation teams delayed reassessment and early intervention.
Improvement recommendations include reviewing clinical governance in the surgery department, strengthening surgical team involvement after patient transfer, and establishing a mechanism for stoma and wound care nursing specialists to conduct assessments and report clinical conditions to surgical teams promptly.
While the hospital officially stated it has accepted all recommendations and is reviewing the professional standards of the doctors involved, sources said more drastic actions are underway behind the scenes.
According to sources, the surgeon involved is an associate consultant-level specialist whose technical competence and professional attitude have come under severe scrutiny. The hospital is currently considering demoting him, refusing to renew his contract, or referring the case to the Medical Council of Hong Kong. "Someone will have to take responsibility," a source said.
Furthermore, sources disclosed that Tseung Kwan O Hospital will restructure its entire surgery department, placing it under the direct control and management of the Kowloon East Hospital Cluster to prevent similar tragedies.
