Assistant Director of the Department of Health (DH) Heston Kwong has apologized to the family of a deceased 77-year-old woman whose remains mistakenly underwent a post-mortem examination at Fu Shan Public Mortuary.

The remains already had been exempted from autopsy requirement prior to Tuesday's operation. The autopsy was supposed to be conducted on the body of a 66-year-old man.

Kwong, making the apology on behalf of the DH, its employees and the mortuary, called the incident "disrespectful to the dead" and "disturbing to the family".

Kwong indicated that some staff members at the mortuary failed to follow proper procedures and some essential requirements in preparation for conducting an autopsy were not carried out.

According to one of those guidelines, a cross check should be carried out to confirm that the name on the bracelet attached to the body conformed with the name on the Coroner's order before the autopsy begins.

The blunder started out on Monday when the Mortuary Director printed a label identifying the female remains as those of a 66-year-old deceased male scheduled to undergo a post-mortem examination. The director's error became compounded when a mortuary assistant removed the female body from the cold storage room on Tuesday.

Another assistant noticed that the woman's remains were not on the autopsy list. When the apparent mistake was pointed out to a doctor, he checked the bracelet on the body against the label on the coroners order and permitted the procedure to go forward.

A senior doctor conducting the autopsy later observed that test samples to be applied to the procedures were not consistent with the female cadaver.

The senior doctor has already been transferred to another position and no longer will be responsible for conducting post mortem examinations. The DH is still investigating the incident and hasn't decided how many staff will be held responsible, said Kwong.

The DH informed the dead woman's family Wednesday afternoon. The family asked to view the body immediately. The family members also requested a written response from the DH in a week, said Kwong.

The 77-year-old female died of heart attack last Sunday. Her family requested exemption from autopsy and obtained the Coroner's approval.

York Chow, secretary for Food and Health, has instructed the DH to conduct a comprehensive review of the current autopsy procedures, and to make a detailed explanation to the family of the deceased as soon as possible.

Kwong stressed that the DH has reiterated to all staff the correct procedure, which is to use the Coroner's order to check identity.

The DH also proposed to introduce an on-duty system in the autopsy room. A doctor will supervise the entire process of the autopsy, handle any possible problems, and provide guidelines.

Kwong believes the new measure will prevent similar mistakes from happening again.

To improve the service at public mortuaries, the DH will also assist all three mortuaries to acquire ISO qualifications, to ensure the periodic review of services.

Kwong denied the incident has anything to do with manpower shortages.

This is not the first time a public mortuary has incorrectly identified bodies. In 2007 a public mortuary at the Prince of Wales Hospital mistakenly released the body of and 88-year-old to the family of a 77-year-old deceased person. That incident also raised the alarm for creating tighter procedures and improving operations.

China Daily

(HK Edition 10/21/2010 page1)