Death of hepatitis B sufferer a reminder to put patient safety first
The plight of a hepatitis B patient who became seriously ill after a medical blunder and died despite two liver transplants touched the hearts of Hong Kong people. The death of Tang Kwai-sze in 2017 also raised many questions concerning the state of the public health system. A coroner’s inquest concluded last week, with a jury returning a verdict of death by misadventure. Lessons need to be learned so that similar tragedies do not occur.
Tang was treated for kidney disease at United Christian Hospital and given a heavy dose of steroids. But two doctors failed to prescribe her the antiviral drugs she needed, as a hepatitis B carrier, to protect her from the virus. She developed a serious liver condition. Her daughter, Michelle Wu, then 17, won the admiration of the community by offering to donate part of her own liver so that her dying mother could have a transplant. But the law required her to be 18 years old. A member of the public stepped forward to become a donor. Sadly, two transplants could not save Tang.
The case highlighted numerous problems. There was an unacceptable delay in the hospital’s reporting of the blunder. Concerns were raised about the workload of hospital doctors, seen as contributing to their mistake.
An investigation found the doctors had shown an “insufficient level of vigilance”. The Medical Council gave them both suspended penalties. They were later charged with manslaughter, raising concerns in the medical profession about the criminal liability of doctors who make errors. Those charges were dropped in August.
The inquest verdict should bring the unhappy story to an end. It will, hopefully, provide some measure of closure for Wu, who was described by the coroner as a “brave, selfless and loving daughter”. She did all she could for her mother. But the lasting impact of the affair should be the prevention of similar blunders in the future. The jury put forward recommendations for improvements, which should be carefully considered by the Hospital Authority along with comments made by the coroner. There is also a need for ongoing health sector reforms to ease the burden on hospital staff.
The heart-rending case should increase awareness of hepatitis B in Hong Kong. It is estimated to affect 6.2 per cent of the population, 465,000 people. But almost half have not been diagnosed. Screening should be expanded, so that timely intervention can be provided. This is being considered by the authorities.
Medical blunders are relatively rare. But they can have serious consequences. The death of Tang should act as a constant reminder of the need to ensure the risks are limited and the safety of patients is put first.