Patient safety: the role of inquests in Hong Kong
We review the part played by inquests in improving patient care in Hong Kong and set out examples of recommendations made at inquests to promote safe practices.
Hong Kong’s latest coroners’ report included a record number of deaths registered and reported to coroners. In 2015 a total of 46,757 deaths were registered, of which 10,767 deaths were reported to the coroners. This is probably linked to the ageing population, which is becoming a major concern in Hong Kong and has put a tremendous strain on public finances and facilities, including hospitals.
In Hong Kong the police will investigate every death that has been reported to coroners. The coroners will consider the police report and the circumstances of each death and decide whether to hold an inquest. One hundred inquests were held in 2015. A significant proportion of these involved deaths connected with medical or surgical care.
Both clinicians and patients need to accept that it is impossible to avoid all human error. However, many errors result from faulty systems and one major function of inquests in Hong Kong is:
“to bring to the attention of a person who may have power to take appropriate action any deficiencies in a system or method of work which are disclosed by the evidence at the inquest and which are of public concern.”
Inquests therefore play a part in patient safety. The clinicians or, more importantly, relevant bodies such as the Hospital Authority, the Department of Health and the Academy of Medicine can implement or correct a system or method of work to control human errors, reduce healthcare burdens and, ultimately, improve patient care.
We set out below three recent examples where important recommendations were made either by coroners or juries.
Example one: private healthcare
While undergoing breast augmentation surgery at a private clinic in a commercial building, a patient suffered breathing problems. She later died of ischaemic brain damage and bronchopneumonia. The death was ruled a misadventure. Concerns were raised over why the surgery was performed in a commercial building rather than a hospital, performed by an obstetrician rather than a plastic surgeon and carried out without an anaesthetist on-site.
A number of recommendations were ordered to be sent to the Medical Council, Academy of Medicine, College of Surgeons and the Plastic Surgery Board, including:
- An in-depth study should be conducted to look into issues relating to the cosmetic surgery industry.
- Guidelines should set out those surgeries or medical procedures which must be performed by a registered doctor or a registered specialist in a relevant speciality.
- Categories of surgery or medical procedures which must be carried out in hospitals, or which can be carried out in private clinics, should be identified.
It is worth noting that the Food and Health Bureau published a consultation report in April 2016, following a wide public consultation on regulating private healthcare facilities. The government says it will take steps to iron out details of the new regulatory regime, with a view to introducing the relevant Bill to the Legislative Council in the 2016/17 legislative session.
Example two: residential care
An elderly person who resided in a care home died of pneumonia and pulmonary tuberculosis caused by influenza A and methicillin-resistant Staphylococcus aureus (MRSA). A number of recommendations were made to the Director of Health, which included:
- The Department of Health should promote public awareness, with specific aims to increase the vaccination coverage among residents and staff in residential care homes for the elderly.
- The existing guidelines on prevention of communicable diseases in residential care homes for the elderly, dating back to 2007, should be updated immediately and then regularly in the future.
Example three: mental health
A patient, who had a history of chronic dyspnoea, suddenly lost consciousness in a home for mentally-ill persons. Various recommendations were made, including:
- Health records of patients should document their conditions. The records should be passed to their families, who should then sign to acknowledge reading and receipt. This will facilitate communications between homes, patients’ families and clinicians who may need this information to devise a medical plan.
- The Social Welfare Department may consider increasing the staffing ratio at homes for mentally-ill persons.
- Staff should be equipped with knowledge of the care needs of patients who have special needs.
The coronial process in Hong Kong has assisted in identifying deficiencies in particular systems and methods of work. It has also helped clinicians to have a broader understanding of patient safety problems.
Patient safety is a global issue. Whilst we cannot correct errors that have led to the death of patients, we can learn from these and put in place sound patient safety infrastructures that aim to reduce the number of people harmed or who die while receiving medical care.