Prince of Wales Hospital Revises Details on Fatal Meal Texture Error Involving 54-Year-Old Patient
Crhk · 8 SOURCESabout 3 hours ago3 MIN
Summary
Prince of Wales Hospital has disclosed additional details surrounding a critical medical safety incident in which a 54-year-old male patient with cognitive impairment and documented swallowing difficulties died after being fed the wrong texture of food. The patient, who required blended meals, was mistakenly served a normal dinner on September 16 and subsequently choked. Legislative Council member Tin Fu-tin said the incident represented clear negligence by nursing staff who failed to review patient records despite the hospital already obtaining the patient's information from family members.
Key Points
- The 54-year-old male patient, who had cognitive impairment, previous stroke, and documented swallowing difficulties requiring blended meals, was admitted to Prince of Wales Hospital on September 16 morning after his mental state deteriorated
- Upon arrival, the patient was assigned a "virtual ID number" because he did not carry identification documents, causing the hospital's dietary management system to default to a normal meal configuration
- Although the doctor ordered "Diet as tolerated" (DAT) based on the patient's clinical condition, ward nurses failed to review the patient's past dietary records to adjust the meal instruction
- At approximately 6:40 PM, a patient services assistant began feeding the patient normal dinner when the patient became distressed, stopped breathing, and experienced cardiac arrest
- Hospital staff immediately performed suction and oxygen therapy while summoning ENT and ICU specialists to remove the airway obstruction, but the patient's condition continued to deteriorate until his death late that night
- Legislative Council member Tin Fu-tin stated that despite the hospital successfully contacting the patient's family and obtaining his information, nurses still failed to review records and serve the correct meal, calling for the nurses involved to be immediately suspended
- The involved nurse and patient services assistant have been temporarily reassigned from clinical duties while the hospital conducts an internal investigation chaired by Tseung Kwan O Hospital chief executive Yuen Ka-yee
Why It Matters
This incident mirrors a similar fatal case at Caritas Medical Centre in March 2025, where another patient requiring blended food died after being fed solid meals due to misinterpretation of "Diet as tolerated" instructions . The recurrence of such preventable errors raises serious questions about the implementation of clinical communication protocols and system safeguards in Hong Kong's public hospitals, despite previous recommendations from the Hospital Authority's root cause analysis committee .
This incident mirrors a similar fatal case at Caritas Medical Centre in March 2025, where another patient requiring blended food died after being fed solid meals due to misinterpretation of "Diet as tolerated" instructions . The recurrence of such preventable errors raises serious questions about the implementation of clinical communication protocols and system safeguards in Hong Kong's public hospitals, despite previous recommendations from the Hospital Authority's root cause analysis committee .