Kwok Cheng Died Of Multi-Organ Failure At Kings College Hospital After Hepatitis B attacked His Organs

A man with Hepatitis B died when medics at Kingston Hospital failed to give him anti-viral medication before he began chemotherapy, leading organ failure, an inquest found.

Kwok Cheng, known as Donald, from Isleworth, was diagnosed with low grade non-Hodgkin’s lymphoma in 2011 and in 2015 was started on a course of chemotherapy.

The inquest into the 58-year-old’s death, held at West London Coroner’s Court last month, heard that, as a Hepatitis B patient, Donald should have been given a course of anti-viral treatment to protect his body from the condition while undergoing cancer treatment. But his consultant failed to do so and Donald suffered multi organ failure and died on July 10, 2016.

Donald’s devastated family instructed expert medical negligence lawyers at Irwin Mitchell to investigate his care under Kingston Hospital NHS Foundation Trust.

At an inquest into the father-of-two’s death on July 21, 2017, coroner Sarah Ormond-Walshe concluded that Donald’s death would have been avoided if the appropriate treatment had been provided.

Delivering her conclusion, Ms Ormond-Walshe said Donald should have received prophylactic medication against reactivation of Hepatitis B virus and, on a balance of probabilities; the treatment would have prevented his death.

The inquest heard that the Trust relied on clinicians at Kingston Hospital determining their patients’ Hepatitis B status by reviewing their virology and serology results before prescribing any medication. If the result showed the patient was positive or there was a risk of Hepatitis B reactivation, they would need anti-viral medication alongside the chemotherapy. But there was no safeguarding system in place before Donald’s death to ensure the medics reviewed the results before beginning treatment.

As a result of Donald’s death, the Trust instigated changes so, before any member of staff can prescribe any medication electronically to a patient, an alert flashes up on screen. This ‘safety net’ asks whether the patient’s virology/serology results have been checked and is designed to ensure prophylaxis is prescribed for those patients who require it.

Richard Kayser, an expert medical negligence lawyer at Irwin Mitchell, representing Donald’s family, said:

Expert Opinion

“While Donald’s family has received a full apology from the Trust, along with an admission of liability from their solicitors, it cannot bring back a much loved husband, son and father.

“To learn that Donald’s death was preventable has added to their grief and their greatest wish now is for lessons to be learned so that what happened to Donald cannot happen to anyone else. It is their hope, and ours, that the new safeguards will ensure that.” Richard Kayser - Partner

Donald was prescribed chemotherapy on October 9, 2015. Three days later checks were made by a pharmacist at Kingston Hospital to ensure he had undergone a virology screen prior to treatment. The results showed a positive Hepatitis B core antibody and the pharmacist informed Donald’s consultant, querying whether anti-viral prophylaxis was required. No further action was taken and there was no safety netting procedures in place at the time to highlight the test result and therefore ensured prophylaxis was given. Donald began six cycles of chemotherapy on October 15.

On June 14, 2016 Donald was admitted to Kingston Hospital’s A&E department suffering with malaise. Tests revealed his Hepatitis B have been reactivated and his condition rapidly deteriorated. He suffered multi-organ failure and died on July 10 with his family at his bedside.

Donald’s son, Anthony, said: “Our family miss my dad so much and we’re all really still struggling to come to terms with his loss.

“We felt there were so many opportunities to ensure he received the right treatment but each was missed. It’s too late for my dad but we hope by highlighting this tragedy other lives will be saved.”