MOH conducting investigation of 103-year-old woman erroneously given 4th dose of COVID-19 vaccine

SINGAPORE: The Ministry of Health (MOH) is conducting a "thorough investigation" of a 103-year-old woman who was erroneously given fourth dose of COVID-19 vaccine, it said on Friday (Feb 4).

The woman, a resident at ECON Healthcare – Chai Chee Nursing Home, was given the fourth dose by a mobile vaccination team from PanCare Medical Clinic in December. She died the following month. 

“The resident had previously received three doses of COVID-19 vaccine, and was erroneously given a fourth shot on Dec 13, 2021,” MOH said. 

“On Dec 16, 2021, the resident was admitted to Changi General Hospital for pneumonia and hyponatremia, and subsequently also diagnosed to have suffered a stroke.”

She died on Jan 10.

“Her death was reported to the coroner, who ordered an autopsy to be conducted. The autopsy found that the main cause of death was pneumonia, with other contributing factors being cerebral infarction (or stroke) and coronary artery disease, which are natural disease processes common in seniors.

“The coroner has not determined whether these causes of death were linked to the vaccination,” MOH said.

The ministry said it “takes a serious view of this incident and is carrying out a thorough investigation”. Investigations are expected to conclude in February.

“Our preliminary findings were that the vaccine was erroneously administered due to possible irregularities in vaccination procedures and poor communication between the nursing home and the medical service provider handling the vaccination,” it said.

“This is the first case of mistaken identity leading to erroneous vaccination by a mobile vaccination team in over 152,000 vaccinations to date.”

In a statement, ECON Healthcare Group said the error was discovered about five minutes after the vaccine was administered.

"The teams from ECON and PanCare attended to the resident, and extended the observation time. The resident had no adverse reaction during that time," it said. 

"ECON and PanCare take a serious view of the incident, and have reviewed our processes to prevent any further recurrence."

It also said that it has been rendering support to the resident's family and "will continue to do so".

MOH added that it planned to announce the incident in December. “However, the family of the resident had requested to withhold details which could have led to the identification of the resident,” it said.

“We have since consulted the family further and are releasing the information to provide clarity on the incident.

“We understand that ECON Healthcare Group and PanCare Medical Clinic have co-funded the resident’s hospital bill as a goodwill gesture. ECON Healthcare has also been in contact with the resident’s family to render support to them."

MOH added: “Both ECON Healthcare and PanCare Medical Clinic have reviewed their processes to prevent a recurrence.  The Agency for Integrated Care, whose role is to facilitate vaccinations in nursing homes, has reminded all nursing homes to ensure proper communications with the mobile vaccination teams when vaccination takes place.

“MOH has also reminded all mobile vaccination teams to perform independent identity verification and authentication before administering any vaccination.”

In response to queries from CNA, PanCare said that it has submitted its version of the circumstances to MOH's investigation team.

"We would like to wait for the completion of the investigation before releasing the findings," it said.

It added that it has been operating the mobile vaccination team for the past eight to nine months, and also operated a vaccination centre as well as be a Public Health Preparedness Clinic vaccination clinic.

"We have always ensured our nurses and doctors are well trained and follow established protocols when vaccinating and will continue to do so," said PanCare.