Read More
The Prince of Wales Hospital has pledged to implement a series of strict intravenous safety overhauls and review its incident reporting policies after an inquest jury unanimously ruled the tragic death of a newborn twin girl in 2023 to be of natural causes.
ADVERTISEMENT
SCROLL TO CONTINUE WITH CONTENT
The ruling on Friday concluded a highly publicized inquiry into the death of the infant, who passed away the day after her birth in June 2023.
Her grieving family had raised concerns that her death was caused by a closed stopcock valve on an intravenous tube, which they believed blocked the flow of vital heart medication.
Along with its natural causes verdict, the Coroner's Court jury recommended that the hospital establish a preliminary notification mechanism to ensure families are kept fully informed during clinical complications.
Responding to the verdict, the hospital expressed deep sadness over the loss and stated it fully respects and will study the jury's recommendations.
The Hospital Authority noted that an early incident reporting system has been in place since 2007 to encourage staff to report operational issues, enabling management to support affected patients and share safety guidelines across the public healthcare sector.
To prevent future occurrences, the hospital has already implemented several strict safety improvements in its neonatal intensive care unit.
These include revising guidelines to mandate visual and physical checks of all intravenous lines and requiring two independent nurses to verify that valves are open when high-risk medications are administered.
Additionally, staff training on clinical equipment has been enhanced, and infusion pump occlusion alarm thresholds have been standardized to trigger much faster when low-dosage medication flow is obstructed.
The hospital is also expanding staff communication training to cultivate a more open, transparent relationship with patients' families during medical emergencies.
