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A 54-year-old male patient with dementia and a history of stroke died at Prince of Wales Hospital after choking on a regular meal that was mistakenly served instead of his required puree diet, public health authorities announced on Friday.
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The public hospital in Sha Tin classified the fatal mishap as a sentinel event and has launched a root cause investigation into how systemic and human lapses led to the dietary mix-up.
Admission under temporary identity triggered default meal order
The patient was rushed to the hospital’s accident and emergency department by ambulance on the morning of September 16 due to a deteriorated mental state, before being transferred to a general medical ward for care.
According to preliminary findings, the man was admitted without identification documents, leading the facility to generate a temporary "pseudo identifier" for his initial registration.
Although the attending physician issued an order for "diet as tolerated" based on his presentation, the hospital’s electronic Dietary and Catering Management System defaulted to assigning regular meals to individuals registered under pseudo identifiers.
The situation was compounded when a nursing staff member failed to thoroughly check the patient’s prior medical records, which would have revealed his dysphagia and previous recommendations by speech therapists for a pureed diet.
As a result, the default regular meal order remained unadjusted.
Emergency resuscitation failed after patient choked during dinner
The tragedy unfolded at around 6:40 p.m. that evening when a patient care assistant began assisting the man with his dinner. The assistant immediately noticed the patient was in distress and halted the feeding to seek urgent help from ward nurses.
Upon examination, nursing staff discovered a sharp decline in the patient's blood oxygen saturation level. Medical teams promptly administered oxygen and attempted suction to clear his airway.
Specialists from the ear, nose, and throat department as well as the intensive care unit were summoned to extract the foreign obstruction from the man's throat.
During the emergency procedure, the patient suffered cardiac arrest and his vital signs continued to deteriorate. Resuscitation efforts were unsuccessful, and he was pronounced dead late that night.
Hospital issues apology and launches comprehensive inquiry
Hospital management expressed deep sorrow over the patient's passing and extended their sincere apologies and condolences to his family during a meeting to explain the sequence of events. Hospital representatives pledged to maintain close contact with the family to provide ongoing assistance.
Immediate remedial actions have been implemented, including reminding clinical personnel to rigorously cross-check clinical conditions and dietary histories before meals are served.
The hospital is also conducting a review of the default meal configurations within its catering system.
Both the nurse and the patient care assistant involved in the incident have been temporarily reassigned to non-clinical duties pending the inquiry.
The hospital has reported the case to the Hospital Authority Head Office through the Advance Incident Reporting System and referred the fatality to the Coroner. An independent root cause analysis panel, chaired by Dr. Kenny Yuen, hospital chief executive of Tseung Kwan O Hospital and Haven of Hope Hospital, has been formed alongside clinical, nursing, and risk management experts to investigate the case, with findings and recommendations expected within eight weeks.
