A coroner ruled that a 43-year-old man died by misadventure after sedation during an endoscopy suppressed his breathing and cardiovascular function, causing low blood oxygen. An earlier forensic report had attributed his death to mitral valve prolapse and valvular heart disease; the coroner said those conditions were not the direct cause.
The man collapsed during an examination at Precision Spec – Surgery & Endoscopy Centre in Tsim Sha Tsui on 10 June 2021 and died that day at Queen Elizabeth Hospital. His wife told the inquest that he had narrowed nasal passages and breathed through his mouth. The coroner listed his heart conditions as other significant conditions.
The doctor who performed the examination testified that he gave the man fentanyl and 100 milligrams of propofol before inserting the endoscope. When the man moved as if trying to pull it out, the doctor gave a further 30 milligrams. A colleague reported that the man’s oxygen level had fallen to 84%; the coroner later said the doctor had needed a nurse’s reminder that it was dropping. The examination stopped, and staff continued resuscitation before the doctor called an ambulance.
An anaesthetist told the inquest that the dose was in the range used for deep sedation to general anaesthesia and that monitoring should be carried out by an anaesthetist or a doctor with relevant training, but Hong Kong had no such requirement at the time. A surgical expert considered the arrangements reasonable and said the doctor was qualified to use propofol under the guidance then in force.
The coroner said the effects of sedatives may be stronger in people with existing respiratory or heart problems. He found insufficient evidence of laryngospasm, citing testimony that the man had shown no stridor or laboured breathing.
The inquest made no recommendations. The widow said she regretted this and that the family was waiting to learn whether anything further would happen after the Medical Council of Hong Kong received the relevant information. She also hoped patients would understand they could ask more about examination procedures and anaesthetic drugs.