Source: Hong Kong Government special administrative region
Hong Kong Children’s Hospital announces root cause analysis report of previous cardiac arrest incident
A 6-year-old boy was admitted to HKCH on December 24, 2025 due to his underlying rare disease. On March 25 this year, he underwent an interventional procedure under general anaesthesia, which was uneventful. Afterwards, he was transferred to the Paediatric Intensive Care Unit (PICU) as planned for ventilator support. At 7.29am on March 26, a nurse found the patient in cardiac arrest. Cardiopulmonary resuscitation was commenced immediately on the patient, and the endotracheal tube connector was found disconnected from the tube and was immediately reconnected to the ventilator circuit. After resuscitation, the patient returned to spontaneous circulation at 7.36am. The hospital subsequently retrieved the patient’s physiological monitor records, which revealed that he had asystole from 7.20am.
HKCH is deeply concerned about the incident and made an announcement on March 28. An RCA panel was formed to conduct a thorough investigation and concluded that the root causes included a combination of factors:
The RCA panel has made the following recommendations for improvement:
HKCH accepted the recommendations of the report and has already begun to implement key improvement measures, including strengthening bedside coverage, handover and equipment safety checks (including alarm volume settings), and will continue to take follow-up actions to enhance patient safety.
The hospital has explained to the patient’s parents the report’s findings and expressed a sincere apology. HKCH will closely communicate with them and render all necessary support. The patient is still hospitalised in the PICU in serious condition. The clinical team will continue to closely monitor his clinical condition and provide appropriate treatment.
The hospital has been following up with the staff concerned in accordance with prevailing human resources policy, including appropriate disciplinary measures where indicated.
The hospital has submitted the report to the Hospital Authority Head Office and expressed gratitude for the work of the Chairman and members of the RCA panel. The membership of the panel is as follows:
Chairman:
Dr Sin Ngai-chuen
Hospital Chief Executive, Alice Ho Miu Ling Nethersole Hospital and Tai Po Hospital
Members:
Dr Janice Chow
Consultant, Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital
Ms Pilta Kan
Nurse Consultant, Department of Paediatrics & Adolescent Medicine, Queen Mary Hospital
Dr Raymond Cheung
Chief Manager (Patient Safety and Risk Management), Hospital Authority
Dr Osburga Chan
Service Director (Quality and Safety), Kowloon Central Cluster
Dr Eric Chan
Deputy Chief of Service, Department of Paediatrics and Adolescent Medicine, Kwong Wah Hospital
Dr Sally Wong
Deputy Quality and Safety Coordinator, Hong Kong Children’s Hospital
Issued at HKT 18:04
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