Kidney patient dies after procedure to insert catheter; incident a ‘medical misadventure’, says coroner

SINGAPORE: A 74-year-old kidney patient died during a procedure to insert a catheter at Tan Tock Seng Hospital after his artery and vein were punctured, said a coroner on Wednesday (Aug 26).

This is believed to be the first such death here, according to a medical expert who was appointed by the Academy of Medicine to look into the case.

Mr Lee Kuen Ngian died on Nov 10, 2016. He had been admitted for peritoneal dialysis, a treatment for kidney failure in which a special sterile fluid is introduced into the abdomen through a permanent tube placed in the peritoneal cavity.

The fluid circulates through the abdomen to draw impurities from surrounding blood vessels in the peritoneum (abdominal cavity), which is then drained from the body.

Mr Lee was assessed to be “medically suitable” for long-term peritoneal dialysis, and it was to be a day surgery.

SURGERY "SEEMED UNEVENTFUL" AT FIRST

On the day of the surgery, Dr See Yong Pey, a consultant at Tan Tock Seng Hospital’s department of renal medicine, started the catheter insertion procedure.

The surgery "seemed uneventful" at first, "with no indication of any presenting complications, and insuffiation of air with the syringe did not show any return of blood suggestive of a bleed", said the coroner's report.

But after air was introduced to his peritoneal cavity, Mr Lee collapsed. The procedure was abandoned and the cannula removed immediately.

While Mr Lee’s pulse returned after a few minutes of resuscitation, he developed two more episodes of “pulseless collapse” and was eventually pronounced dead.

Forensic pathologist Dr Chan Shijia concluded that the cause of death was acute haemorrhage due to punctured right common iliac artery and right common iliac vein during peritoneal dialysis catheter insertion procedure.

Mr Lee’s underlying hypertension and IgA (Immunoglobulin A) nephropathy were cited as contributory factors.

PROCEDURE OUTSIDE OF A RENAL PHYSICIAN'S SCOPE OF PRACTICE: MEDICAL EXPERTS

Two medical experts appointed by the Academy of Medicine gave their input during the inquiry, with one of them, Dr Cheng Shin Chuen, noting that the procedure Mr Lee underwent was “outside the scope of practice for a renal physician in Singapore”.

Dr Cheng, a specialist surgeon from Mount Elizabeth Novena Specialist Centre, also expressed his view that Dr See "most likely punctured the arteries and vein unknowingly with a faulty technique; he basically passed the sharp point of the trocar all the way in, injuring the artery and vein at the same time".

Dr Cheng also said that Dr See’s cannula insertion technique fell short of what is an “acceptable level of competency” and caused a “wholly preventable puncture of the right common iliac vessels, leading to the unfortunate demise of this patient”.

The other expert, Dr Tan Chieh Suai, a consultant in the department of renal medicine at Singapore General Hospital, “expressed his concern that Dr See had undertaken the procedure only slightly after two months of being granted this clinical privilege and performing 23 independent insertions of peritoneal catheters”.

He added that to the best of his knowledge, this is the first case of such a death here.

"TRULY UNFORTUNATE MEDICAL MISADVENTURE": CORONER

Coroner Marvin Bay said Mr Lee's death is a "truly unfortunate medical misadventure”, and that there is no basis to suspect foul play. 

“Evidence nevertheless points strongly to Mr Lee’s demise from the acute haemorrhage having occurred when both the trocar and cannula punctured through Mr Lee’s right common iliac artery and right common iliac vein during the catheter insertion procedure to enable Mr Lee to undergo peritoneal dialysis, with hypertension and IgA nephropathy being contributing factors to his eventual demise," he added.

The court also recommended that the circumstances of the mishap leading to Mr Lee’s death be “closely investigated with a view to the establishment of a commonly acceptable protocol of ‘best-practices’ for such procedures”.

“This would be all the better to prevent such tragic recurrences to patients hoping to avail themselves to the therapeutic benefits of peritoneal dialysis," the coroner said.