Xia Baolong Concludes Two-Day Inspection Visit to Hong Kong

Director of Hong Kong and Macao Work Office of CPC Central Committee and Hong Kong and Macao Affairs Office of State Council Mr Xia Baolong concludes inspection visit to Hong Kong 

The Director of the Hong Kong and Macao Work Office of the Communist Party of China Central Committee and the Hong Kong and Macao Affairs Office of the State Council, Mr Xia Baolong, today (June 17) conducted the second day of his inspection visit to Hong Kong.

Accompanied by the Chief Executive, Mr John Lee; the Financial Secretary, Mr Paul Chan; and the Secretary for Security, Mr Tang Ping-keung, Mr Xia this morning visited the new Huanggang Port to learn about the redevelopment of the port.

Mr Xia then visited Kwai Chung Container Terminal 8 to understand the latest development of the shipping industry in Hong Kong. The National 15th Five-Year Plan Outline explicitly supports Hong Kong in consolidating and enhancing its status as an international shipping centre. During his visit, Mr Xia was briefed by the Secretary for Transport and Logistics, Ms Mable Chan, on the situation of the ports. He also exchanged views with the industry practitioners.

Mr Xia later met with Mr Lee and Principal Officials at Government House, where he also held discussions to exchange views with community representatives.

Mr Xia concluded his two-day inspection visit and departed Hong Kong in the afternoon.

The Director of the Hong Kong and Macao Work Office of the Communist Party of China Central Committee and the Hong Kong and Macao Affairs Office of the State Council, Mr Xia Baolong (fifth right), today (June 17) holds discussions to exchange views with community representatives in the company of the Chief Executive, Mr John Lee (sixth right), at Government House. Source: HKSAR Government Press Releases

The Director of the Hong Kong and Macao Work Office of the Communist Party of China Central Committee and the Hong Kong and Macao Affairs Office of the State Council, Mr Xia Baolong (centre), today (June 17) meets with the Chief Executive, Mr John Lee (third left) at Government House. Source: HKSAR Government Press Releases

The Director of the Hong Kong and Macao Work Office of the Communist Party of China Central Committee and the Hong Kong and Macao Affairs Office of the State Council, Mr Xia Baolong (third left), today (June 17) visits Kwai Chung Container Terminal 8 in the company of the Chief Executive, Mr John Lee (second left), and is briefed by the Secretary for Transport and Logistics, Ms Mable Chan (first right), on the situation of the ports. Source: HKSAR Government Press Releases

The Director of the Hong Kong and Macao Work Office of the Communist Party of China Central Committee and the Hong Kong and Macao Affairs Office of the State Council, Mr Xia Baolong (first left), today (June 17) visits Kwai Chung Container Terminal 8 in the company of the Chief Executive, Mr John Lee (second right), and exchanges views with the industry practitioners. Source: HKSAR Government Press Releases

The Director of the Hong Kong and Macao Work Office of the Communist Party of China Central Committee and the Hong Kong and Macao Affairs Office of the State Council, Mr Xia Baolong (tenth right), today (June 17) visits the new Huanggang Port in the company of the Chief Executive, Mr John Lee (ninth right). Source: HKSAR Government Press Releases

The Director of the Hong Kong and Macao Work Office of the Communist Party of China Central Committee and the Hong Kong and Macao Affairs Office of the State Council, Mr Xia Baolong (second left), today (June 17) visits the new Huanggang Port in the company of the Chief Executive, Mr John Lee (third left). Source: HKSAR Government Press Releases

Tseung Kwan O Hospital announces root cause analysis report of previous sentinel event

The following is issued on behalf of the Hospital Authority:

The spokesperson for Tseung Kwan O Hospital (TKOH) today (June 18) announced the root cause analysis (RCA) report of a sentinel event regarding a stoma surgery:

An 85-year-old female patient with obstructive sigmoid colon cancer underwent a transverse colostomy on February 7 this year to relieve intestinal obstruction. After surgery, the patient was admitted to the Intensive Care Unit and surgical ward of TKOH for monitoring and was subsequently transferred to Haven of Hope Hospital on February 16 for rehabilitation. Her vital signs remained stable, but the stomal output was relatively high. On March 1, the patient developed hypotension and tachycardia and was transferred back to the surgical ward of TKOH on March 2 for treatment and an emergency computed tomography scan. The scan revealed that the stoma was located at the stomach instead of the intended transverse colon. The patient's condition subsequently deteriorated. Family members discussed the case with the clinical team and agreed to Do-Not-Attempt Cardiopulmonary Resuscitation for the patient. The patient passed away on the evening of March 3.

The hospital is deeply concerned about the incident and has referred the case to the Coroner for follow-up. The incident was flagged as a sentinel event, and an RCA Panel was formed to investigate the root cause of the incident. The hospital Patient Relations Team has explained the report's findings to the patient's family and expressed apology again to them. The team shall continue to render all necessary assistance to the family.

The RCA Panel conducted a thorough investigation into the causes of the incident and concluded that:

1. The surgeon exhibited confirmation bias when identifying abdominal cavity structures, wrongly exteriorised the stomach instead of the transverse colon during the surgery, without performing additional confirmation measures; and

2. Two days prior to the patient's transfer, healthcare staff did not recognise that the stomal output had shown an increasing trend, and the patient was transferred for rehabilitation as planned; healthcare staff providing rehabilitation services lacked relevant experience in managing patients who had recently undergone stoma surgery; and inadequate communication between the surgical and rehabilitation teams, resulting in a lack of timely monitoring and verification of the patient's abnormal stomal output, which subsequently delayed reassessment and early intervention.

The Panel has made the following recommendations for improvement:

1. Review the clinical governance of the surgery department, especially the clinical decisions made by the surgical specialist responsible for supervising the operation, and the arrangements for transferring a post-operative patient presented with unexpected clinical features to a medical rehabilitation facility for management;

2.Strengthen the involvement of the surgical team in the clinical management after a post-operative patient is transferred for rehabilitation; and

3.Establish a mechanism to ensure that stoma and wound care nursing specialists conduct assessments for post-operative stoma patients, properly documenting the patient's fluid balance and stomal output, and ensure that the patient's clinical conditions are reported to the surgical team in a timely manner.

The hospital accepted the recommendations of the report and has implemented relevant improvement measures to enhance patient safety, including reviewing clinical governance mechanisms across surgical decision making, transfer arrangements and interdisciplinary communication on clinical management. The system for stoma and wound care nurses to evaluate patients who have just undergone stoma surgery has been standardised, and communication with the surgical team has been reinforced.

TKOH is also taking measures to restructure the clinical governance and management framework of the Department of Surgery in TKOH, by formulating a cluster-based Surgery Department to further strengthen governance and enhance patient safety. The hospital will follow up with the doctors concerned in accordance with prevailing human resources procedures, and will review the professional standard of the doctors. If necessary, the case will be referred to the Medical Council of Hong Kong to follow up.

TKOH has submitted the report to the Hospital Authority Head Office and expressed gratitude for the work of the Chairman and members of the RCA Panel. The membership of the panel is as follows:

Chairman:

Dr Tang Kam-shing

Hospital Chief Executive, Kwong Wah Hospital

Members:

Dr Cheung Ka-yin

Consultant, Department of Medicine and Geriatrics, United Christian Hospital

Dr Raymond Cheung

Chief Manager, Quality & Safety Division (Patient Safety & Risk Management), Hospital Authority

Dr Victor Ip

Service Director (Quality and Safety), Kowloon East Cluster

Dr Henry Joeng

Chief of Service, Department of Surgery, United Christian Hospital

Dr Lawrence Lai

Consultant, Department of Medicine & Geriatrics, Pok Oi Hospital and Tin Shui Wai Hospital

Dr Lok Hon-ting

Chief of Service, Department of Surgery, Prince of Wales Hospital and Shatin Hospital

Ms Shit Kam-yee

Nurse Consultant (Stoma and Wound Care), New Territories East Cluster

Source: AI-found images