A 54-year-old man with cognitive impairment, a previous stroke and swallowing difficulties died after being fed a standard dinner at Prince of Wales Hospital, despite requiring pureed food, according to the hospital’s account of the incident.
The man was taken by ambulance to the hospital’s emergency department on 16 September after his mental state deteriorated and was admitted to a medical ward. He arrived without identification documents and was registered using a virtual identity number.
The hospital’s preliminary investigation found that its nutrition and meal-management system defaulted patients with virtual identity numbers to a normal diet. A nurse had not completed a review of the man’s previous dietary records, so a standard dinner was assigned even though he had swallowing difficulties and needed pureed food.
At about 6.40pm, a patient service assistant began feeding him. The assistant noticed that he was unwell, stopped feeding and sought help from a nurse. His blood oxygen level had fallen, and medical staff suctioned him and provided oxygen. Ear, nose and throat and intensive-care doctors removed the airway obstruction, but he suffered cardiac arrest during the emergency response and died later that night.
The hospital said its later review of the man’s history found that he had needed frequent hospital treatment and that a speech therapist had assessed him as having swallowing difficulties requiring pureed food. The hospital met his family, apologised, expressed its condolences and offered assistance. The nurse and patient service assistant involved were temporarily removed from clinical duties.
Staff were reminded to assess patients’ clinical condition and dietary instructions and to check meal-system settings before arranging food. The hospital reported the incident through its early reporting system, established a root-cause analysis committee and said it would complete a report with improvement recommendations within eight weeks. The case was also referred to the coroner.