New details emerge in fatal dialysis case

Many medical experts say it is necessary to clarify the cause of the death of 8 victims of the dialysis incident in Hoa Binh.

Dr. Le Thanh Hai, Director of the Institute of Medical Equipment and Construction (TTB-CTYT), Ministry of Health - representative of a group of scientists on medical equipment, has just said that the cause of death of the 8 victims in the dialysis accident in Hoa Binh is still a big question mark that needs to be clarified.

"If it was poisoning, all the patients would have been poisoned, not just 8 people who died. One of the victims died, but when examined, the HF rate was 0.02, while the threshold of 0.05 is still safe, proving that the death was due to another cause," Mr. Hai wondered.

According to Dr. Hai, one of the factors related to the cause of death of the patient on dialysis is that 3 water valves of the RO1 system were broken, but the police investigation agency has not yet clarified the impact of these 3 valves on the entire system.

"The Institute of Medical Equipment and Technology has redrawn the drawings of the entire RO1 and RO2 water treatment systems and the scientists of Medical Equipment have carefully, meticulously, and objectively analyzed the science to clearly show that the 3 valves (K1; K2; K3) of the RO1 system were broken at the same time on the same road, which is very rare" - Mr. Hai commented.

Mr. Hai further analyzed that due to long-term use, repeated flushing and maintenance with chemicals in the past, the 3 valves had gradually deteriorated, causing water to leak through the first 2 filter columns and many impurities to float away due to backwashing of the first filter columns of RO1 (not meeting dialysis standards) into the RO2 system. Doctor Hoang Cong Luong had noticed some unusual clinical manifestations in patients during previous dialysis, and had requested maintenance of the water system.

At Hoa Binh Provincial General Hospital, the RO1 system supplies water for washing the filter, the RO2 system supplies water for running the kidney machine, so logically, Dr. Luong's request for maintenance of the RO2 system is correct, this shows that Dr. Luong's professional intuition is very good. The unexpected thing is that the damage from the RO1 system has directly polluted the circulation for artificial kidney dialysis.

Many victims were treated by doctors.

According to scientists in the fields of emergency resuscitation, forensics, medical equipment, chemistry, toxicology and law of the Ministry of Health, the failure of 3 water valves in the RO1 system directly connected the polluted water source from the raw filtration system that had not gone through the RO membrane of the RO1 system to the RO2 for the hemodialysis machine, which was the cause of the death of 8 patients. This is a new detail that has not been included in the investigation conclusion and cannot be the residue of HF chemicals as previously stated by the investigation agency.

Mr. Hai said the question raised by the Ministry of Health was how much substance was in the victims' blood, but so far the authorities have not had an answer. Meanwhile, the Investigation Police Agency of Hoa Binh Public Security has destroyed the entire RO1 and RO2 systems, the most important evidence of the case, without a complete, objective, and scientific on-site experiment.

"I propose that the police investigate and reconstruct the entire crime scene and conduct an experimental investigation with the witness and cooperation of medical scientists to carefully, objectively, and scientifically find the cause of death for the patients," Dr. Hai suggested.

Mr. Nguyen Huy Quang, Director of the Legal Department (Ministry of Health), said that the latest information on the case will also be reported by the Ministry of Health to the Prime Minister. Previously, after the appeal hearing in mid-June 2019, the Ministry of Health held a meeting with experts on medical equipment, health, lawyers, etc. to re-evaluate the entire case and consider the request for a review of the above judgment.