HONG KONG | A fatal surgical error at Tseung Kwan O Hospital has become a major patient-safety case after an internal review found that a surgeon misidentified organs during an operation on an 85-year-old woman and created a stoma in the stomach rather than the colon.
The South China Morning Post reported that the woman had obstructive sigmoid colon cancer and underwent a procedure intended to relieve an intestinal blockage. The hospital's root-cause analysis linked the outcome to confirmation bias, diagnostic error, poor monitoring and delayed intervention. The patient later developed low blood pressure and an increased heart rate, was transferred back to Tseung Kwan O Hospital, and a scan showed the stoma had been created in the stomach. She died on March 3.
The case is difficult because it involves both an individual error and system questions. Surgical teams rely on training, anatomical identification, cross-checks, escalation procedures and post-operative monitoring. When one of those layers fails, another should catch the problem. The hospital report suggests several layers did not work quickly enough.
Confirmation bias is especially important in medicine. Once a clinician believes a structure is what they expect to see, later signs can be interpreted through that assumption. In surgery, that risk is why verification, team communication and willingness to reconsider are crucial. A wrong-site or wrong-organ outcome is not merely a complication. It is a sentinel event that demands institutional review.
The reporting also notes calls for accountability, including criticism from a former lawmaker who urged dismissal of the surgeon. Employment discipline, professional licensing and hospital-safety changes are separate decisions, but public confidence depends on whether the response addresses both the clinician's conduct and the system that allowed the error to continue undetected.
For Hong Kong patients, the case raises broader questions about transparency. Hospitals must protect patient privacy, but serious medical errors require public explanation when they reveal safety vulnerabilities. The central issue now is whether the Hospital Authority and the hospital can show that new safeguards will prevent a repeat.
Additional Reporting By: South China Morning Post; Tseung Kwan O Hospital public materials; Hong Kong Hospital Authority materials reviewed by CGN News; CGN News Hong Kong Bureau.