Report of the Select Committee to
inquire into the handling of
the Severe Acute Respiratory Syndrome outbreak by
the Government and the Hospital Authority
July 2004

TABLE OF CONTENTS

CHAPTERS
Page
1Introduction

1 - 16

2The case of AA in the Kwong Wah Hospital

17 - 26

3Gathering of information/intelligence about epidemic of infectious diseases in the Mainland and strategy/ contingency plan of the Hospital Authority for dealing with a large-scale outbreak of an infectious disease

27 - 37

4The M Hotel Cluster

38 - 42

5Quarantine and Prevention of Disease Ordinance (Cap. 141)

43 - 64

6Outbreak at the Prince of Wales Hospital

65 - 106

7Outbreak at the Alice Ho Miu Ling Nethersole Hospital

107 - 121

8Outbreak at the Amoy Gardens

122 - 148

9Outbreak at the United Christian Hospital

149 - 160

10Outbreak at the Princess Margaret Hospital

161 - 187

11Outbreak at the Tai Po Hospital

188 - 200

12Outbreak at the Tuen Mun Hospital

201 - 212

13Infection control measures in hospitals

213 - 232

14Command structure of the Government and the Hospital Authority in the handling of the SARS outbreak

233 - 248

15Conclusions and Recommendations

249 - 261

Signatures of members of the Select Committee

263
Appendices
Appendix IPractice and procedure of the Select Committee267 - 279

Appendix IILists of organizations and individuals which/who made submissions to the Select Committee

280 - 281

Appendix IIISchedule of hearings and names of witnesses

282 - 291

Appendix IVNotes of meeting on 22 May 2004 between the Chief Executive and members of the Select Committee

292 - 317

Appendix VPseudonyms used in the Report

318

Appendix VIA chronology of important events and activities during the SARS outbreak at the Prince of Wales Hospital

319 - 322

Appendix VII13 New Territories East Cluster guidelines issued by Dr Donald LYON between 14 March and 31 March 2003 for hospitals in the New Territories East Cluster

323

Appendix VIIIOther issues raised at the meeting on 5 April 2003 attended by Dr Stephen NG Kam-cheung, Dr YEOH Eng-kiong, Dr Trevor Maxwell ELLIS, Dr Thomas TSANG Ho-fai, Mr YUEN Ming-chi, Dr LO Su-vui and Dr Paul SAW Thian-aun

324 - 332

Appendix IXIndex patients of Wards 3DR, 4BR and 4DR in the Tai Po Hospital

333

Appendix XQuestionnaire on "Measures relating to Personal Protective Equipment during Outbreak of Severe Acute Respiratory Syndrome"

334 - 339

Appendix XIAnalysis of responses to the questionnaire on "Measures relating to Personal Protective Equipment during Outbreak of Severe Acute Respiratory Syndrome"

340 - 362

Lists of written evidence/documents

AEvidence/documents provided by the Administration and related persons

366 - 381

BEvidence/documents provided by the Hospital Authority and related persons

382 - 399

CEvidence/documents provided by witnesses and other persons

400 - 407

DEvidence/documents provided by universities, medical professional bodies/individuals and other parties

408 - 411

Minutes of proceedings

415 - 434

Minutes of evidence of public hearings

Table of Contents

No.Date of public hearingWitness
113 December 2003 Miss YANG Siu-fan
Registered Nurse, Kwong Wah Hospital
Dr CHOW Kin-wa
Medical Officer, Accident and Emergency Department, Kwong Wah Hospital
Dr WU Chun-wah
Consultant, Accident and Emergency Department, Kwong Wah Hospital
Dr LUK Che-chung
Hospital Chief Executive, Kwong Wah Hospital
216 December 2003 Dr Melissa HO (Khin Khin Tint)
Infection Control Officer, Kwong Wah Hospital
Dr WATT Chi-leung
Consultant (Director), Intensive Care Unit,Kwong Wah Hospital
Dr York CHOW Yat-ngok
Cluster Chief Executive (Hong Kong West)/Hospital Chief Executive, Queen Mary Hospital
320 December 2003 Professor HO Pak-leung
Associate Professor, Division of Infectious Diseases, Department of Microbiology, Faculty of Medicine,The University of Hong Kong
Professor Kenneth TSANG Wah-tak
Associate Professor, Specialty Division of Respiratory and Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of Hong Kong
Dr SETO Wing-hong
Chief of Service, Department of Microbiology,Queen Mary Hospital/Infection Control Officer,Hong Kong West Cluster
46 January 2004 Ms KWOK Lai-yin
Deputy Ward Manager (Nurse Specialist),Intensive Care Unit, Kwong Wah Hospital
Dr TSANG Hin-hung
Senior Medical Officer, Intensive Care Unit,Kwong Wah Hospital
Dr Andrew YIP Wai-chun
Chief of Service, Department of Surgery,Kwong Wah Hospital
Dr LIU Shao-haei
Senior Executive Manager (Professional Services), Hospital Authority
(Convenor of the Central Committee on Infection Control (named the Task Force on Infection Control before 4 March 2003) and the Working Group on Severe Community-Acquired Pneumonia of the Head Office of the Hospital Authority)
(Dr LIU Shao-haei has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Professor YUEN Kwok-yung
Head/Clinical Professor (Chair of Infectious Diseases), Department of Microbiology, Faculty of Medicine,The University of Hong Kong
510 January 2004 Dr TSE Lai-yin, JP
Consultant Community Medicine in-charge, Disease Prevention and Control Division, Department of Health
Professor Joseph SUNG Jao-yiu
Chairman, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong/Chief of Service, Department of Medicine and Therapeutics, Prince of Wales Hospital
(Professor Joseph SUNG Jao-yiu has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
612 January 2004 Dr Margaret CHAN FUNG Fu-chun
Former Director of Health
713 January 2004 Dr Margaret CHAN FUNG Fu-chun
Former Director of Health
817 January 2004 Dr FUNG Hong, JP
Cluster Chief Executive (New Territories East)/Hospital Chief Executive, Prince of Wales Hospital
920 January 2004 Dr Donald James LYON
Consultant, Department of Microbiology,Prince of Wales Hospital/Infection Control Officer, New Territories East Cluster
Mr Albert NG Hon-yui
Department Operations Manager, Department of Medicine and Therapeutics, Prince of Wales Hospital
Mr CHAN Man
Deputizing Nursing Officer, Department of Medicine and Therapeutics, Prince of Wales Hospital
Dr David HUI Shu-cheong
Head of Division of Respiratory Medicine/Associate Professor, Department of Medicine and Therapeutics, Faculty of Medicine,The Chinese University of Hong Kong
1031 January 2004 Professor Sydney CHUNG Sheung-chee
Dean, Faculty of Medicine, The Chinese University of Hong Kong
113 February 2004 Dr LUI Siu-fai
Service Director (Risk Management and Quality Assurance), New Territories East Cluster
Professor WONG Tze-wai
Department of Community and Family Medicine, Faculty of Medicine, The Chinese University of Hong Kong
Dr Louis CHAN Yik-si
Medical Officer, Department of Obstetrics and Gynaecology/Officer-in-charge, Disease Control Centre, Prince of Wales Hospital
Ms CHAN Kit-hoi
Department Operations Manager, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital
Ms TSANG Sou-wah
General Manager (Nursing), Alice Ho Miu Ling Nethersole Hospital
Ms Lily CHUNG Choy-lan
Service Director (Nursing), New Territories East Cluster
127 February 2004 Dr CHAN Hok-sum
Consultant Physician, Department of Medicine,Alice Ho Miu Ling Nethersole Hospital
Dr Raymond CHEN Chung-i
Hospital Chief Executive, Alice Ho Miu Ling Nethersole Hospital
Dr AU Tak-kwong
Community Physician (New Territories East), Department of Health
Dr Thomas TSANG Ho-fai
Consultant Community Medicine (Communicable Disease), Disease Prevention and Control Division, Department of Health
1310 February 2004 Dr KO Wing-man, JP
Director (Professional Services and Public Affairs), Hospital Authority
(Dr KO Wing-man, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
1414 February 2004 Dr KO Wing-man, JP
Director (Professional Services and Public Affairs), Hospital Authority
(Dr KO Wing-man, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
1517 February 2004 Dr LEUNG Pak-yin, JP
Deputy Director of Health
1621 February 2004 Ms CHIU Wing-mui
Former Ward Manager of Ward 12A,United Christian Hospital
Ms CHAN Yuet-kwai
General Manager (Nursing), United Christian Hospital
Dr LAI Wai-man
Infection Control Officer, United Christian Hospital
Ms CHAN Nim-chi
Department Operations Manager, Department of Medicine and Geriatrics, United Christian Hospital
Dr Edward LEUNG Man-fuk
Chief of Service, Department of Medicine and Geriatrics, United Christian Hospital
1724 February 2004 Dr LAU Fei-lung
Chief of Service, Accident and Emergency Department, United Christian Hospital
Dr TSE Chun-yan
Cluster Chief Executive (Kowloon East)/Hospital Chief Executive, United Christian Hospital
Ms Winnie CHAN Kwan-ying
Department Operations Manager, Intensive Care Unit, Princess Margaret Hospital
(Ms Winnie CHAN Kwan-ying has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
Ms Adela LAI Shuet-fun
General Manager (Nursing), Princess Margaret Hospital
(Ms Adela LAI Shuet-fun has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
1828 February 2004 Dr Thomas SO Man-kit
Senior Medical Officer, Infectious Disease Team, Department of Medicine and Geriatrics, Princess Margaret Hospital
(Dr Thomas SO Man-kit has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr YU Wai-cho
Consultant Physician, Department of Medicine and Geriatrics, Princess Margaret Hospital
(Dr YU Wai-cho has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr NG Tak-keung
Infection Control Officer, Princess Margaret Hospital
(Dr NG Tak-keung has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr Stephen NG Kam-cheung
192 March 2004 Dr YAN Wing-wa
Consultant, Intensive Care Unit,Princess Margaret Hospital
(Dr YAN Wing-wa has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr Thomas Anthony BUCKLEY
Chief of Service, Intensive Care Unit,Princess Margaret Hospital
Dr Matthew TONG Kwok-lung
Chief of Service, Department of Medicine and Geriatrics, Princess Margaret Hospital
(Dr Matthew TONG Kwok-lung has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr Lily CHIU Lee-lee
Cluster Chief Executive (Kowloon West)/Hospital Chief Executive, Princess Margaret Hospital
(Dr Lily CHIU Lee-lee has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
206 March 2004 Dr William HO Shiu-wei, JP
Chief Executive, Hospital Authority
(Dr William HO Shiu-wei, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
219 March 2004 Dr LEONG Che-hung, GBS, JP
Chairman, Hospital Authority
(Dr LEONG Che-hung, GBS, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr Sarah LIAO Sau-tung, JP
Secretary for the Environment, Transport and Works
Professor Joseph SUNG Jao-yiu
Chairman, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong/Chief of Service, Department of Medicine and Therapeutics, Prince of Wales Hospital
(Professor Joseph SUNG Jao-yiu has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
2213 March 2004 Dr YEOH Eng-kiong, JP
Secretary for Health, Welfare and Food
2316 March 2004 Dr YEOH Eng-kiong, JP
Secretary for Health, Welfare and Food
2420 March 2004 Dr LIU Shao-haei
Senior Executive Manager (Professional Services), Hospital Authority
(Convenor of the Central Committee on Infection Control (named the Task Force on Infection Control before 4 March 2003) and the Working Group on Severe Community-Acquired Pneumonia of the Head Office of the Hospital Authority)
(Dr LIU Shao-haei has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr CHEUNG King-on
Consultant in-charge, Intensive Care Unit,Caritas Medical Centre
Dr HUI Yim-wo
Senior Medical Officer, Department of Paediatrics, Princess Margaret Hospital
2523 March 2004 Dr TAM Cheuk-yin
Consultant Physician, Department of Medicine and Geriatrics, Tuen Mun Hospital
(Dr TAM Cheuk-yin has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr LEE Tsun-woon
Chief of Service, Department of Anaesthesia and Intensive Care, Tuen Mun Hospital
(Dr LEE Tsun-woon has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr QUE Tak-lun
Infection Control Officer, Tuen Mun Hospital
(Dr QUE Tak-lun has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr Simon CHOW Liang
Chief of Service, Department of Medicine and Geriatrics, Tuen Mun Hospital
(Dr Simon CHOW Liang has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Dr CHEUNG Wai-lun
Cluster Chief Executive (New Territories West)/ Hospital Chief Executive, Tuen Mun Hospital
(Dr CHEUNG Wai-lun has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
2627 March 2004 Dr YEOH Eng-kiong, JP
Secretary for Health, Welfare and Food
273 April 2004 Mr LAM Woon-kwong, GBS, JP
Director of the Chief Executive's Office
2817 April 2004 Mr LAM Woon-kwong, GBS, JP
Director of the Chief Executive's Office
2920 April 2004 Dr YEOH Eng-kiong, JP
Secretary for Health, Welfare and Food
Mr Boris TO Hing-kuen
Ward Manager, Tai Po Hospital
(Mr Boris TO Hing-kuen has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
Ms Maria CHUI Yeuk-ping
Department Operations Manager,Department of Medicine and Geriatrics, Shatin Hospital
(Ms Maria CHUI Yeuk-ping has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
Ms Helena LI Yuk-lin
General Manager (Nursing), Tai Po Hospital
(Ms Helena LI Yuk-lin has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
Dr TUNG Sau-ying
Hospital Chief Executive, Tai Po Hospital
(Dr TUNG Sau-ying has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
3024 April 2004 Dr LO Su-vui
Head, Research Office, Health, Welfare and Food Bureau
Dr Paul SAW Thian-aun
Dr Trevor Maxwell ELLIS
Senior Veterinary Officer (Veterinary Laboratory), Veterinary Laboratory Division,Agriculture, Fisheries and Conservation Department
Mr YUEN Ming-chi
Pest Control Officer-in-charge, Pest Control Advisory Section, Food and Environmental Hygiene Department
Dr Thomas TSANG Ho-fai
Consultant Community Medicine (Communicable Disease), Disease Prevention and Control Division, Department of Health


The above post titles were those held by the witnesses at the time when they attended the hearings of the Select Committee