【明報專訊】SEVEN YEARS AGO, an incident of ''missed prescription'' occurred at United Christian Hospital (UCH), after which hepatitis B patient Tang Kwai-Sze suffered from liver failure and died after undergoing two liver transplants. Yesterday (7 May) the Coroner's Court ruled that she ''died of misadventure'', marking the end of the judicial procedures regarding her case. However, many crucial details remain unclear.
Although the victim's daughter stated in court that she had reservations about the testimonies of some witnesses from the hospital, after the authorities dropped the charges of manslaughter against the doctors involved last year, it would be difficult for the victim's family to pursue their accountability further. The five recommendations made by the Coroner's Court to the Hospital Authority (HA) regarding Tang's case were mainly technical improvement measures to prevent similar tragedies from happening again –– the key still being the doctors' careful and focused attentiveness towards patients.
In early 2017, Tang Kwai-Sze went to UCH for a follow-up consultation on her kidney disease. Although the hospital had a record of Tang being a carrier of hepatitis B since 2008, when the two senior specialists prescribed her steroids for her kidney disease, they failed to simultaneously prescribe antiviral medication to prevent the activation of the hepatitis B virus in her body, which could lead to hepatitis. In April of the same year, Tang was hospitalised because of acute hepatitis. She underwent two liver transplant surgeries but died eventually.
According to the information revealed, on 6 April that year, UCH was already aware that Tang had not been prescribed antiviral medication. However, it was not until two weeks later, in response to the family's inquiries, that the hospital disclosed the ''drug prescription blunder'' and reported it to the HA. Afterwards, the HA issued an investigation report, which concluded that the two doctors involved had a ''lack of vigilance'', but the incident did not involve concealment in any regard, only ''inadequate communication''.
As for the two doctors involved, they were found guilty of professional misconduct by the Medical Council in 2021, resulting in a suspension of their licences for three and five months respectively. They received suspended sentences and remained in practice at UCH afterwards. Early last year, the police arrested the two doctors involved in the incident and charged them with manslaughter, causing an uproar in the medical community. They believed that the professional monitoring of doctors' performance by the Medical Council had ''proved effective'' and objected to methods of criminal prosecution.
Some doctors even argued that with the manpower shortages and long working hours at public hospitals, it is difficult to determine whether the ''mistakes committed in haste'' by doctors should be attributed to personal or systemic causes. If a precedent of doctors being charged with manslaughter over a medical mishap is set, it may result in a work-to-rule campaign by doctors and exacerbate the resignation wave. At last, the Department of Justice applied to drop the charges, which was approved by the court. To Tang's family, this Coroner's inquest has become their last chance to seek the truth through legal channels.
The jury ruled yesterday that Tang ''died of misadventure''. That means they were convinced that the reactivation of hepatitis B was due to Tang's intake of steroids without the prescription of antiviral medication. Her death was caused by medication, which should be categorised as an injury rather than a disease. It was not caused by an autoimmune disorder (i.e., death by natural causes). Tang's family has been seeking justice for many years. The ruling by the Coroner's Court ascertained that Tang's death was neither ''death by natural causes'' nor ''death by undetermined causes'', but rather death by injury. The Coroner also commended the victim's eldest daughter for her strength and courage, hoping that the family could find closure and move on from their grief.
明報社評 2024.05.08：開漏藥害命教訓慘痛 細心專心防悲劇重演
聯合醫院7年前發生「開漏藥」事件，乙型肝炎女病人鄧桂思事後出現肝衰竭，兩度換肝後不治，死因庭昨天裁定「死於不幸」，有關鄧桂思案的司法程序，至此告一段落，惟仍有不少關鍵細節未能釐清。
雖然死者女兒庭上陳辭，對醫院方面部分證人的供辭明言有保留，然而隨着當局去年撤銷起訴涉事醫生誤殺，死者家屬亦難再進一步追究責任。死因庭就鄧案向醫管局提出5項建議，主要屬技術性的改善措施，防止同類悲劇重演，關鍵仍在於醫生對病人的細心和專心。
2017年初，婦人鄧桂思因腎病到聯合醫院覆診。雖然院方2008年已有鄧婦是乙型肝炎帶菌者的紀錄，可是兩名資深專科醫生給她處方類固醇治療腎病時，皆未有同步處方抗病毒藥物，以防鄧婦體內的乙肝病毒變得活躍引發肝炎。同年4月，鄧婦急性肝炎入院，兩度接受換肝手術，最終不治。
資料顯示，聯合醫院當年4月6日已知道鄧婦之前未獲處方抗病毒藥，可是兩周後才應家屬查詢，交代「開漏藥」一事，並向醫管局通報。事後醫管局發表調查報告，認為涉事兩名醫生「警覺度不足」，惟事故不涉隱瞞掩飾，只是「溝通不足」。
至於涉事兩名醫生，醫委會2021年裁定他們專業失當，分別除牌3及5個月，同獲緩刑。兩人之後仍在聯合醫院工作。去年初，警方拘捕涉事兩名醫生，控以誤殺，醫生業界群情洶湧，認為由醫委會專業監管醫生表現「行之有效」，反對刑事追究。
有醫生更稱，公院人手少工時長，醫生「忙中有錯」難以判定屬個人或系統責任，若因醫療事故被控誤殺，先例一開，可能引發醫生按章工作及加劇離職潮。最終律政司申請撤銷控罪，獲法庭批准。對鄧桂思家屬而言，今次死因聆訊，已成為他們循司法途徑了解真相的最後機會。
陪審團昨天裁定鄧桂思「死於不幸」，意即認為鄧服用類固醇卻未獲處方抗病毒藥，導致乙肝復發，死亡乃是藥物引起，屬於傷害而非疾病，並非自身免疫系統失調所致（即死於自然）。鄧桂思家屬為討公道奔走多年，死因庭裁決確認鄧既非「死於自然」，亦非「死因存疑」，而是傷害致死，死因裁判官對死者長女的堅強勇敢，也加以肯定，唯盼家屬可以釋懷，走出傷痛。
■/ Glossary 生字 /
concealment：the act of hiding something; the state of being hidden
work-to-rule：a situation in which workers refuse to do any work that is not in their contracts, in order to protest about something
ascertain：to find out the true or correct information about something