Hoa Binh dialysis accident: Chemical residue 260 times higher

The expert conclusion shows that the water sample in the dialysis accident in Hoa Binh has a fluoride content 260 times higher than the permitted level.

Chemical residue is 260 times higher

On the morning of May 28, before the serious medical incident, Quoc went to the hospital to carry out the contract. Quoc and Son checked the quantity, quality, and design of the materials according to the contract.

Quoc proceeded to replace the filter material, clean the two old filter membranes, replace the two new filter membranes, operate and repair the filter columns. Next, the defendant closed the valves at the inlet to the dialysis machine and sterilized the water supply pipe system for the dialysis machine within 2 hours.

Finally, Quoc drained all the remaining water, used a pump to pump new RO water into the pipe to continuously wash it for 2 hours, drained the faucet head again and then reconnected the wire as before.

At around 6:30 p.m. the same day, Quoc called Son to inform him that the repairs and maintenance had been completed, but Son was not there, so he called Do Thi Diep, a nurse at the Intensive Care Unit, to lock the water room door. Son said that the equipment was working normally and that he would sign the handover minutes tomorrow.

At around 7:00 a.m. on May 29, nurses from the Intensive Care Unit and the hemodialysis unit started the water filtration system.

Next, Dr. Hoang Cong Luong, after examining the patients who were eligible for dialysis and seeing that the nurses had completed the procedures, gave the order for dialysis to each patient.

At about 8:15 a.m., while 18 patients were receiving dialysis treatment, an incident occurred.

During the investigation, the Institute of Criminal Science of the Ministry of Public Security established a special working group to re-examine the machines used to serve patients during hemodialysis.

The assessment results show that the water samples collected here and fed into dialysis machines No. 10 and No. 13 have very low pH levels; very high conductivity, and Floura content is 245 and 260 times higher than the permissible level.

Police executed arrest warrants for the suspects.

Arrest 3 suspects

As reported, on June 22, regarding the kidney dialysis accident that killed 8 people, Hoa Binh Provincial Police issued a decision to prosecute and execute an arrest warrant to temporarily detain three suspects.

Among them, Bui Manh Quoc (31 years old, residing in Bac Ninh City, Director of Tram Anh Water Treatment Company Limited) was prosecuted for the crime of Involuntary manslaughter due to violating professional rules.

Tran Van Son (27 years old, residing in Hoa Binh city, officer of the medical equipment and supplies department - Hoa Binh General Hospital) was prosecuted for the crime of Lack of responsibility causing serious consequences.

Hoang Cong Luong (31 years old, residing in Quoc Oai, Hanoi, Doctor of Intensive Care Department - Artificial Kidney Unit, Hoa Binh Provincial General Hospital) was prosecuted for the crime of Violating regulations on medical treatment.

According to the initial investigation results, at the end of April 2017, Tran Van Son went directly to the hospital's water treatment room to check and discovered that the RO water filtration system No. 2 had a broken starter.

Son proposed to replace the materials and it was approved. The defendant directly discussed with Thien Son Pharmaceutical Joint Stock Company about the need for repair and maintenance and product quotation.

On May 25, the hospital signed a contract with Thien Son Company to provide materials to repair RO water filtration system No. 2 for the unit.

On the same day, this company signed a contract with Tram Anh Water Treatment Company Limited, directed by Bui Manh Quoc, to sell, install, and replace RO filter material No. 2 at Hoa Binh General Hospital.

Hoa Binh Provincial General Hospital, where the dialysis accident occurred

Careless, irresponsible

Police determined that due to carelessness, after cleaning, Bui Manh Quoc forgot to drain both ends into the machine, leaving chemical residue in the water pipes leading to the dialysis machine. Although it was not known whether the water met the standards or not, Quoc still handed it over to Tran Van Son for use.

On Son's side, although he had professional qualifications and was aware that the equipment had to be tested for safety before being put into use, he had not yet tested it, had not yet handed it over in writing, and had not yet checked the actual maintenance and repair work, but had notified the nurse of the Intensive Care Department for Dialysis Patients.

Regarding Dr. Hoang Cong Luong, although he had not received a written handover of the repair work and did not know whether the RO water source No. 2 met the standards or not, he still allowed the patients to undergo dialysis. The defendant's actions showed a lack of responsibility and a serious violation of regulations on medical examination and treatment.

According to PLO