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The panel, comprising Professor Howell Tong, a Pro-Vice-Chancellor of HKU, Dr Walton Li, Deputy Medical Superintendent of Hong Kong Sanatorium & Hospital and Professor Raymond Liang, an Associate Dean of HKU's Faculty of Medicine, has completed its investigation and issued its report today (April 23).
Professor Howell Tong, Chairman of the Panel, said,"This has been a very thorough investigation. The panel has collected as much evidence as it can and studied all the evidence carefully before making its recommendations. The report will be forwarded to the Vice-Chancellor for his consideration."
Professor So Kwok-fai, Head of the Department of Anatomy, said,"The findings are fair and acceptable. The Department will certainly follow the recommendations of the Panel. We in fact have already started to review our entire procedures for the handling and disposal of cadavers and body parts and are setting up a proper record-keeping system for body parts. This indeed is a valuable lesson for us and we will make sure that there will be no recurrence of such an incident."
A copy of the executive summary is attached for your reference. A copy of the full report can be viewed at: http://www.hku.hk/eroonweb/human_parts_report.doc.
For media enquiries, please contact Miss Polo Leung at HKU's External Relations Office at 2859 2600.
REPORT OF THE INVESTIGATION PANEL ON THE DISCOVERY OF HUMAN BODY PARTS AT THE TSEUNG KWAN O LANDFILL SITE
Executive Summary
BACKGROUND
(1) On 3rd and 4th January, 2003, it was extensively reported in the media that five human body parts were discovered at the Tseung Kwan O Landfill site, which were believed to be originally in the possession of the Department of Anatomy, Faculty of Medicine, the University of Hong Kong. On 7th January, the Vice-Chancellor of the University, appointed a panel comprising the following members to undertake an investigation into the course of events leading to this incident:
- Professor Howell Tong, Pro-Vice-Chancellor, HKU (Chairman)
- Dr Walton Li, Deputy Medical Superintendent of Hong Kong Sanatorium & Hospital
- Professor Raymond Liang, Associate Dean, Faculty of Medicine, HKU
To assist the investigation of the panel, the University also appointed an independent consultant to advise the panel on whether there had been any irregularities in the process of demolition works by any parties concerned, which might account for the incident.
(2) During the process of investigation, the panel visited the demolition site at the old Li Shu Fan Building, the present premises of the Department of Anatomy at the new medical building, and the Kowloon Public Mortuary. The panel met with the police and the forensic pathologist as well as interviewed relevant staff members of the Department of Anatomy, Estates Office, Safety Office and demolition contractor.
FINDINGS
Human Parts
(3) After a thorough investigation, the panel is of the view that among the several possible scenarios, the most probable was that some human body parts were left behind in one of the mortuary chambers, although it has not been able to come to a definite conclusion in respect of the precise sequence of events leading to the incident. The panel was informed that there was hidden space (which was used by the Department to store body parts because of shortage of storage space) between the floor panel and the lowest movable tray in the mortuary chamber and that a door of one of the chambers was known to be malfunctioning. The panel cannot completely rule out the possibility that the five human body parts which were later discovered at the Tseung Kwan O landfill site were stored in the hidden space behind the malfunctioning door. The panel was of the view that the officers-in-charge might not have opened the malfunctioning door during their checking before the relocation of the cadavers and human body parts, but instead relied on shining a torch at an angle after opening an adjacent functioning door of this particular mortuary chamber. There was the possibility that, with the reflection from the translucent heavy-duty polythene bag(s) containing the body parts (if indeed they were stored at the hidden space behind the malfunctioning door) and the obstruction of vision due to the trays and steel bars inside the mortuary chamber, a blind spot would have been created and these translucent bag(s) might have been mistaken for the floor panel below the hidden space.
(4) The panel observed that some, if not all, of the human parts were wrapped in torn heavy-duty polythene bags when discovered at the landfill site, and the records of the dumping trucks also confirm that the debris containing the human parts was likely to have come from the demolition of the Cadaver Store. It was therefore not impossible that they were mixed with the general debris when the demolition workers pushed down the mortuary chambers from the wall behind with their heavy machinery. The body parts then went unnoticed by the workers for the following reasons: (i) the poor lighting condition at the demolition site; (ii) the body parts, having been treated with formalin, had acquired such a soil-like colour that a casual glance could not readily distinguish them from the debris; and (iii) the debris was delivered mechanically to a dump truck by a backhoe machine.
(5) It is the opinion of the panel that the probability of this incident taking place could have been drastically reduced if the Department had a proper system of record-keeping in respect of the body parts. The panel discovered that the Department had a proper system to record the number of whole cadavers. However, it did not keep any record of un-dissected body parts, which were retained for future use.
Disposal of Clinical/Biohazard Waste
(6) The panel has also considered carefully the related issue of clinical/biohazard waste and concluded that, apart from an unopened packet with a new syringe needle inside, it was not able to find any evidence that untreated clinical/biohazard waste might have been left in the Animal Laboratory at the Li Shu Fan site. However, the panel finds the unopened packet a regrettable occurrence even though the article was not readily discernible among the general debris. Furthermore, it finds that some critical aspects of the move exercise from the Li Shu Fan Building to the new Faculty of Medicine Building have been unsatisfactory. It is of the view that the Estates Office should have been more proactive in instituting effective coordination, which would have assisted the departments in the move and the clearing up of chemicals left behind in the old building. The role of the Safety Office in such a relocation exercise is also not clearly defined giving rise to gaps in the safety procedures of the University.
RECOMMENDATIONS
(7) While the panel does not think that the evidence allows it to hold any single individual or group of individuals wholly responsible for the sequence of events leading to the unfortunate incident of the human parts being dumped and discovered at the Tseung Kwan O landfill site, it is of the view that there are unquestionably issues of institutional responsibilities, especially in respect of the Department of Anatomy, for not installing a record-keeping system for the un-dissected human parts and providing adequate support to and supervision of the officers-in-charge of handling the cadavers and human body parts during the move exercise. The Estates Office should have been more proactive in instituting a system of effective coordination for moving departments/units from one site to another. Accordingly, the panel does not think it appropriate to take disciplinary action against any individual, but makes the following recommendation:
Recommendation 1: The Department of Anatomy should be reprimanded.
(8) To prevent similar incidents in the future and to further strengthen the safety measures, the panel has also made the following recommendations:
RECOMMENDATION 2: The Department of Anatomy should (i) maintain an effective record-keeping system in respect of cadavers, un-dissected human body parts, prosected materials, plastinated materials, human parts in Perspex containers, and any other similar items (e.g. human skeletons, human organs and others) under its care; (ii) review the record-keeping system annually, taking into consideration any major changes in the teaching method, faculty structure and others; and (iii) revise the system whenever necessary.
(In this regard, the panel is pleased to note that immediately after the incident, the Department of Anatomy has been proactive and taken swift action to review its daily operation and procedures, the record-keeping system and to identify problem areas.)
On the ethical side, the panel feels that the Department of Anatomy should take this opportunity to reiterate to its students the significance of treating the cadavers and body parts with proper respect.
RECOMMENDATION 3: In all future moves of similar magnitude, the University should have a mechanism which exercises centralized control, via the Estates Office, of the different tasks, with a simple and effective communication line at both the user's end and the service provider's end so as to maximize co-ordination.
RECOMMENDATION 4: The University should make a policy decision on the precise role of the Safety Office in relocation exercise of this nature.
RECOMMENDATION 5: The Safety Office should be authorized to be the granting agent for (i) safe-to-move clearance, without which no department/unit is allowed to move and (ii) safe-to-demolish clearance, without which no University building is allowed to be demolished.
HKU to release the Investigation report on human parts discovered at Tseng Kwan O Landfill Site
23 Apr 2003
On January 7th, Professor Lap-Chee Tsui, the Vice-Chancellor of the University of Hong Kong (HKU) appointed a panel to undertake investigation into the course of events leading to human parts originally in the possession of the Faculty of Medicine being discovered at the Tseng Kwan O landfill site on January 3rd and 4th.
The panel, comprising Professor Howell Tong, a Pro-Vice-Chancellor of HKU, Dr Walton Li, Deputy Medical Superintendent of Hong Kong Sanatorium & Hospital and Professor Raymond Liang, an Associate Dean of HKU's Faculty of Medicine, has completed its investigation and issued its report today (April 23).
Professor Howell Tong, Chairman of the Panel, said,"This has been a very thorough investigation. The panel has collected as much evidence as it can and studied all the evidence carefully before making its recommendations. The report will be forwarded to the Vice-Chancellor for his consideration."
Professor So Kwok-fai, Head of the Department of Anatomy, said,"The findings are fair and acceptable. The Department will certainly follow the recommendations of the Panel. We in fact have already started to review our entire procedures for the handling and disposal of cadavers and body parts and are setting up a proper record-keeping system for body parts. This indeed is a valuable lesson for us and we will make sure that there will be no recurrence of such an incident."
A copy of the executive summary is attached for your reference. A copy of the full report can be viewed at: http://www.hku.hk/eroonweb/human_parts_report.doc.
For media enquiries, please contact Miss Polo Leung at HKU's External Relations Office at 2859 2600.
REPORT OF THE INVESTIGATION PANEL ON THE DISCOVERY OF HUMAN BODY PARTS AT THE TSEUNG KWAN O LANDFILL SITE
Executive Summary
BACKGROUND
(1) On 3rd and 4th January, 2003, it was extensively reported in the media that five human body parts were discovered at the Tseung Kwan O Landfill site, which were believed to be originally in the possession of the Department of Anatomy, Faculty of Medicine, the University of Hong Kong. On 7th January, the Vice-Chancellor of the University, appointed a panel comprising the following members to undertake an investigation into the course of events leading to this incident:
- Professor Howell Tong, Pro-Vice-Chancellor, HKU (Chairman)
- Dr Walton Li, Deputy Medical Superintendent of Hong Kong Sanatorium & Hospital
- Professor Raymond Liang, Associate Dean, Faculty of Medicine, HKU
To assist the investigation of the panel, the University also appointed an independent consultant to advise the panel on whether there had been any irregularities in the process of demolition works by any parties concerned, which might account for the incident.
(2) During the process of investigation, the panel visited the demolition site at the old Li Shu Fan Building, the present premises of the Department of Anatomy at the new medical building, and the Kowloon Public Mortuary. The panel met with the police and the forensic pathologist as well as interviewed relevant staff members of the Department of Anatomy, Estates Office, Safety Office and demolition contractor.
FINDINGS
Human Parts
(3) After a thorough investigation, the panel is of the view that among the several possible scenarios, the most probable was that some human body parts were left behind in one of the mortuary chambers, although it has not been able to come to a definite conclusion in respect of the precise sequence of events leading to the incident. The panel was informed that there was hidden space (which was used by the Department to store body parts because of shortage of storage space) between the floor panel and the lowest movable tray in the mortuary chamber and that a door of one of the chambers was known to be malfunctioning. The panel cannot completely rule out the possibility that the five human body parts which were later discovered at the Tseung Kwan O landfill site were stored in the hidden space behind the malfunctioning door. The panel was of the view that the officers-in-charge might not have opened the malfunctioning door during their checking before the relocation of the cadavers and human body parts, but instead relied on shining a torch at an angle after opening an adjacent functioning door of this particular mortuary chamber. There was the possibility that, with the reflection from the translucent heavy-duty polythene bag(s) containing the body parts (if indeed they were stored at the hidden space behind the malfunctioning door) and the obstruction of vision due to the trays and steel bars inside the mortuary chamber, a blind spot would have been created and these translucent bag(s) might have been mistaken for the floor panel below the hidden space.
(4) The panel observed that some, if not all, of the human parts were wrapped in torn heavy-duty polythene bags when discovered at the landfill site, and the records of the dumping trucks also confirm that the debris containing the human parts was likely to have come from the demolition of the Cadaver Store. It was therefore not impossible that they were mixed with the general debris when the demolition workers pushed down the mortuary chambers from the wall behind with their heavy machinery. The body parts then went unnoticed by the workers for the following reasons: (i) the poor lighting condition at the demolition site; (ii) the body parts, having been treated with formalin, had acquired such a soil-like colour that a casual glance could not readily distinguish them from the debris; and (iii) the debris was delivered mechanically to a dump truck by a backhoe machine.
(5) It is the opinion of the panel that the probability of this incident taking place could have been drastically reduced if the Department had a proper system of record-keeping in respect of the body parts. The panel discovered that the Department had a proper system to record the number of whole cadavers. However, it did not keep any record of un-dissected body parts, which were retained for future use.
Disposal of Clinical/Biohazard Waste
(6) The panel has also considered carefully the related issue of clinical/biohazard waste and concluded that, apart from an unopened packet with a new syringe needle inside, it was not able to find any evidence that untreated clinical/biohazard waste might have been left in the Animal Laboratory at the Li Shu Fan site. However, the panel finds the unopened packet a regrettable occurrence even though the article was not readily discernible among the general debris. Furthermore, it finds that some critical aspects of the move exercise from the Li Shu Fan Building to the new Faculty of Medicine Building have been unsatisfactory. It is of the view that the Estates Office should have been more proactive in instituting effective coordination, which would have assisted the departments in the move and the clearing up of chemicals left behind in the old building. The role of the Safety Office in such a relocation exercise is also not clearly defined giving rise to gaps in the safety procedures of the University.
RECOMMENDATIONS
(7) While the panel does not think that the evidence allows it to hold any single individual or group of individuals wholly responsible for the sequence of events leading to the unfortunate incident of the human parts being dumped and discovered at the Tseung Kwan O landfill site, it is of the view that there are unquestionably issues of institutional responsibilities, especially in respect of the Department of Anatomy, for not installing a record-keeping system for the un-dissected human parts and providing adequate support to and supervision of the officers-in-charge of handling the cadavers and human body parts during the move exercise. The Estates Office should have been more proactive in instituting a system of effective coordination for moving departments/units from one site to another. Accordingly, the panel does not think it appropriate to take disciplinary action against any individual, but makes the following recommendation:
Recommendation 1: The Department of Anatomy should be reprimanded.
(8) To prevent similar incidents in the future and to further strengthen the safety measures, the panel has also made the following recommendations:
RECOMMENDATION 2: The Department of Anatomy should (i) maintain an effective record-keeping system in respect of cadavers, un-dissected human body parts, prosected materials, plastinated materials, human parts in Perspex containers, and any other similar items (e.g. human skeletons, human organs and others) under its care; (ii) review the record-keeping system annually, taking into consideration any major changes in the teaching method, faculty structure and others; and (iii) revise the system whenever necessary.
(In this regard, the panel is pleased to note that immediately after the incident, the Department of Anatomy has been proactive and taken swift action to review its daily operation and procedures, the record-keeping system and to identify problem areas.)
On the ethical side, the panel feels that the Department of Anatomy should take this opportunity to reiterate to its students the significance of treating the cadavers and body parts with proper respect.
RECOMMENDATION 3: In all future moves of similar magnitude, the University should have a mechanism which exercises centralized control, via the Estates Office, of the different tasks, with a simple and effective communication line at both the user's end and the service provider's end so as to maximize co-ordination.
RECOMMENDATION 4: The University should make a policy decision on the precise role of the Safety Office in relocation exercise of this nature.
RECOMMENDATION 5: The Safety Office should be authorized to be the granting agent for (i) safe-to-move clearance, without which no department/unit is allowed to move and (ii) safe-to-demolish clearance, without which no University building is allowed to be demolished.
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