A 29-year-old Hong Kong man died of misadventure linked to a rare complication following a gastroscopy at a public hospital two years ago, a death inquest has found.
The Coroner’s Court on Friday ruled that Lui Pak-to died of cerebral oedema, or brain swelling, triggered by the procedure at Queen Mary Hospital on February 29, 2024.
Coroner Raymund Chow Chi-wei cited expert evidence indicating it was undesirable that Lui had to wait four hours and 40 minutes for a brain scan after suffering a seizure that afternoon.
However, Chow said Lui’s condition deteriorated too rapidly for the hospital to arrange hyperbaric oxygen therapy – a treatment involving pure oxygen in a pressurised chamber – at another institution.
He also noted that the complication was so rare that implementing preventive measures for every patient would be impractical.
No recommendations were made to the Hospital Authority regarding the case.
The court heard that Lui was first admitted to Tin Shui Wai Hospital after feeling nauseous while hiking on December 7, 2022.
He was later transferred to Tuen Mun Hospital, where he was diagnosed with a ruptured stomach, likely caused by the accidental ingestion of a corrosive substance.
Psychological reports stated that Lui said he had taken an unidentified substance without realising the consequences and denied suicidal intent or anxiety disorders.
He underwent two surgeries and was discharged pending a further operation to reconstruct his digestive tract. However, he suffered a seizure and fell into a coma after undergoing a gastroscopy at Queen Mary Hospital on February 29, 2024. He was pronounced dead the following day.
An autopsy found the direct cause of death to be cerebral oedema, with brain haemorrhage and bleeding beneath surrounding tissues identified as contributing factors.

All three medical experts engaged by the court agreed that gas may have entered Lui’s circulatory system through his damaged oesophagus during the examination, blocking blood vessels shortly before his death.
While gas is commonly used to inflate the digestive tract during gastroscopy, air embolism – the complication Lui suffered – is exceptionally rare, occurring in just 0.44 per 100,000 cases.
Dr Yip Hon-chi, assistant professor in the Department of Surgery at the Chinese University of Hong Kong, raised concerns about the size of the endoscope initially planned for use but noted that doctors ultimately opted for a thinner tube.
He found no evidence that scars in Lui’s digestive tract were caused by the endoscope during the procedure.
Dr Sheng Bun, a consultant in the department of medicine and geriatrics at Princess Margaret Hospital, said an earlier diagnosis might have been possible had the gastroscopy been conducted sooner.
Dr Wong Wai-tat, associate clinical professor in the department of anaesthesia and intensive care at the Chinese University of Hong Kong, said it was “not very appropriate” for Queen Mary Hospital’s radiology department to delay Lui’s scan due to a long waiting list.
However, he added that the delay could be understandable if time was needed to bring Lui’s seizure under control.
He also said the gastroscopy was essential ahead of Lui’s gastrointestinal reconstruction surgery and that its risks were unavoidable.
Lui’s widow, Chiu Wan-kei, questioned why the hospital took so long to examine her husband despite his critical condition.
She said the inquest had failed to provide a full picture, as the radiologists involved were not called to testify.
“Something still remains a mystery,” she added.
The South China Morning Post has contacted the authority for comment.

Original source: cn