Fluoride Action Network

Hoa Binh hospital deaths: Dialysis machine water bad

Source: VietnamNet | June 26th, 2017
Location: Vietnam

VietNamNet Bridge – Water used for kidney dialysis in Hoa Binh General Hospital, where eight patients died recently, in one of Viet Nam’s most serious medical incidents, did not meet standards, tests revealed.

The Ministry of Public Security’s Criminal Science Institute arrived at the conclusion after analysing samples.

Water samples from dialysis machines number 10 and 13 had a low level of potential of hydrogen (pH) and high conductivity; the florua level in machines number 10 and 13 were 245 and 260 times higher, respectively, than permissible limit of Association for the Advancement of Medical Instrumentation (AAMI).

The other dialysis machines tested also had higher florua levels than permitted.

According to AAMI, the maximum florua level allowed in the kidney dialysis water is 0.2 mg per litre.

Investigations revealed that Bui Manh Quoc, director of Tram Anh Water Treatment Co. Ltd., which maintained and replaced the Reverse Osmosis (RO) filter system of dialysis machines, used chemicals to purify the system. During the process, however, the machines’ water supply tubes were not purified carefully, leaving chemical residue. After pasteurisation of RO filter system, Quoc did not check quality of water samples before handing the system over to the hospital.

Last week, the Hoa Binh police arrested three people suspected to be responsible for the incident. They were prosecuted in a criminal case.

Quoc, 31, is being investigated for unintentional manslaughter, following the violation of professional and/or administrative rules.

Tran Van Son, 27, an employee from the hospital’s medical equipment department, is being investigated for failing to supervise the water filter process.

Nephrologist Hoang Cong Luong, 31, has been arrested for medical violations as Luong allowed the dialysis treatment to commence without checking water quality.

Truong Quy Duong, director of Hoa Binh General Hospital, and two other employees have been suspended pending investigation into suspected negligence that led to the incident.

On May 29, 18 patients underwent kidney dialysis treatment in the northern province’s general hospital. Soon, they reported nausea, abdominal pain and shortness of breath.

The same day, eight patients died of suspected anaphylactic shock. The remaining 10 patients were transferred to Ha Noi’s Bach Mai Hospital and have recovered.

Further investigation is ongoing.

*Original article online at http://english.vietnamnet.vn/fms/society/180938/hoa-binh-hospital-deaths–dialysis-machine-water-bad.html

See also:

• July 7, 2017: Bad water might be cause of kidney calamity: experts

• June 26, 2-17: Hoa Binh hospital deaths: Dialysis machine water bad

• June 25, 2017: Chemical in dialysate hundred times higher than allowable level

• June 5, 2017: One more patient dies in medical incident in Hoa Binh

• May 30, 2017: Six out of 18 dialysis patients died during treatment