22 May 1999

Medical institutions should learn serious lessons
from Coroner¡¦s recommendations

(Keywords:- dialysis mishap, private hospitals, standard, monitoring)

          The long awaited verdict and recommendations of the death inquest on the three tragic deaths during haemodialysis in a private hospital was finally delivered. As expected, the return was that of accidental death, and rightly so, because there has been, and there could never be, an intent to bring about the loss of life.

          Regrettably, whatever the verdict, nothing will bring back the lives so lost, nor comfort the relatives and friends of the victims. Let us hope that the incident itself and the recommendations made by the Coroner and the different investigatory reports on the same tragedy will be lessons learnt by all to avoid further mishaps!

          Worthy of note, of course, are the recommendations made at the inquest which will have wide ranging and long term effect. Rightly so, the recommendations touch on Government¡¦s overall monitoring mechanism, the structure and management of the private hospital and the control of the machine supplier involved. These are golden mottos that any parties involved in health care must take heed.

          Improvements must start from the root. In this case when biomedical machines are needed for patient¡¦s treatment, proper control on the suppliers is vital. Yes, a proper set of guideline instruction both in English and Chinese is essential and must be followed to the letter by both the health care personnels and the mechanics alike. There is as yet no demand for standards of biomedical technicians nor even control on most imported nor locally produced biomedical equipments. Ironically, nowadays, even electricians must be properly licensed.

          Recommendations are made for improvement of clinical monitoring in hospitals, in particular private institutions. These are commendable. It would be inconceivable in these days of specialisation and high tech medicine that service providers, under the auspices of hospital management, do not set up clinical management teams  to decide policy, vet staff standards, and monitor the running of services to provide the public the confidence that life saving procedures are adequately and properly scrutinised.

          Hospitals are institutions for the care of the sick for which input by specialist health care providers into the management structure are essential for proper functioning. The Coroner is dead on right to suggest that Board membership and management structure of hospitals should be reviewed to ensure the active involvement of specialist consultants in full time professional practice.

          As medical sciences rapidly advance, staff training and topping up of knowledge is paramount. Compulsory training, compulsory continued medical education for registration purpose in the different disciplines of health care should be the norm rather than the exception. After all, a commitment to a health care profession is a commitment to life long learning.

          Finally, the Department of Health as the registrar of licence for private health care institutions cannot be absolved from responsibility. It must be the expected role of this Department to function as a catalyst to facilitate the recommendations so far made, and to ensure their proper implementation.

          It is not just enough for the Department to make frequent spot checks. It must act as a standard bearer, producing practical guidelines for the different institutions to follow so as to assure the public that the licensed institutions have reached at least the minimum required standard.

          Medical incidents have happened before, they are happening today, and unfortunately, with all the good intentions, they will still happen in the future. It is for the Government, the medical equipment suppliers, the service providers and the public to cooperate to minimize the mishaps and to maximise the benefit.

(Hongkong Standard)