Patient who needed soft food dies after choking on regular meal at public hospital

A Hong Kong patient passed away after suffering a heart attack while being given a regular meal instead of the necessary soft food at Prince of Wales Hospital. The public hospital located in Sha Tin released a public apology on Friday and revealed that an eight-member panel would investigate the error. A comprehensive report, including recommendations for improvement, is anticipated within eight weeks.

The 54-year-old male patient was admitted to the hospital on Wednesday morning due to a deteriorating mental state. Since he lacked identification upon admission, the hospital created a "pseudo identifier" for registration purposes. Given his clinical condition, the attending physician ordered a "diet as tolerated," or DAT, for the nursing staff. DAT typically means that a patient should consume food and fluids at a level they are comfortable with.

However, the hospital's catering management system automatically assigns regular meals to patients registered under a pseudo identifier. A nursing staff member failed to verify the patient's previous diet records before adjusting the diet order, resulting in a regular meal being served to the individual that evening. The patient began feeling unwell while being fed by a patient care assistant.

Doctors were called to assist in removing the obstruction in the patient's airway; however, he went into cardiac arrest during the emergency treatment. His condition worsened, and he died late that night.

Upon reviewing the patient's history post-incident, the hospital discovered that he had been hospitalized frequently before due to underlying diseases, including dementia and a history of stroke. A speech therapy assessment had recommended a purée diet due to the patient's difficulty swallowing. The hospital expressed deep sorrow over the death and had met with the patient's family to explain the incident, offering sincere apologies and condolences.

The hospital has implemented immediate measures, such as reminding healthcare staff to thoroughly assess patients' clinical conditions and diet orders before assigning meal arrangements and reviewing the default meal setting of their dietary and catering management system. The nursing staff member and patient care assistant involved have been temporarily reassigned to non-clinical duties.

A similar mistake occurred at Caritas Medical Centre in March of the previous year, where a 75-year-old patient choked to death after a nurse misunderstood the doctor's instructions due to a communication error and served him solid food instead of the required puréed diet.