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Brian Wong

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, an 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 in Pok Fu Lam 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.
But 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.
But 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 could 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, an air embolism – the complication Lui suffered – is exceptionally rare, occurring in just 0.44 per 100,000 cases.
Dr Yip Hon-chi, an assistant professor of the department of surgery at the Chinese University of Hong Kong (CUHK), raised concerns about the size of the endoscope initially planned to use but noted that doctors had 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, an associate clinical professor at CUHK’s anaesthesia and intensive care department, 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.
“Some things still remain a mystery,” she added.
A Queen Mary Hospital spokesman said it respected the court’s verdict, while highlighting its doctors had provided the patient with “appropriate treatment”.


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The Coroner’s Court ruled that Lui Pak-to died of cerebral oedema following a gastroscopy at Queen Mary Hospital on February 29, 2024. Photo: Jelly Tse

Experts told the inquest that a rare air embolism was likely to have occurred during the procedure before the patient fell into a coma and died the following day. Photo: Winson Wong

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A report into the alleged blunder at Tuen Mun Hospital is expected within eight weeks. Photo: Jelly Tse

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Law and Crime

Coroner rules death caused by brain swelling after procedure at Queen Mary Hospital in 2024, with rapid deterioration limiting treatment options


Coroner rules death caused by brain swelling after procedure at Queen Mary Hospital in 2024, with rapid deterioration limiting treatment options.


Hong Kong healthcare and hospitals

Hospital Authority

Queen Mary Hospital

Accidents and personal safety in Hong Kong

Hong Kong inquest finds rare gastroscopy complication caused man’s death

.css-1c6uqr6{color:inherit;font-weight:inherit;font-size:inherit;font-family:inherit;line-height:inherit;overflow-wrap:break-word;}Coroner rules death caused by brain swelling after procedure at Queen Mary Hospital in 2024, with rapid deterioration limiting treatment options

Coroner rules death caused by brain swelling after procedure at Queen Mary Hospital in 2024, with rapid deterioration limiting treatment options