SINGAPORE – In what is the first reported baby mix-up in a public hospital, two sets of parents went home on Sunday from KK Women’s and Children’s Hospital (KKH) with the wrong babies.
The mistake was discovered about an hour after one of the couples got home and noticed the identifying tag – which hospital staff tie around every newborn’s ankle – of the baby they brought back did not bear the mother’s name.
After blood tests were carried out to verify that the baby did not belong to the first couple, the second set of parents were notified of the mistake at around midnight on Sunday, after they had spent around 10 hours at home with the baby whom they thought was theirs.
While the babies have been returned to their rightful parents, the results of DNA tests to confirm the identity of the two boys will only be known by the end of this week.
Yesterday, KKH released a media statement at about 7.20pm on the mix-up. Calling it an “unfortunate incident”, the hospital said it “unreservedly apologises to the parents for this error and will take all steps to prevent any recurrence”.
At a press conference last night, KKH Chief Executive Officer Kenneth Kwek – who was present along with the Chairman of the hospital’s medical board, Mr Alex Sia, and Director of Nursing Tan Soh Chin – also apologised and pledged that there will be no repeat of such a mistake in the future. “This is a terrible incident … it is the first and will be the last time,” he said.
Adding that the hospital is reviewing all its processes, Mr Kwek said the hospital is providing the families with support, including counselling.
The Ministry of Health (MOH) was informed of the mix-up yesterday morning. The MOH said: “We are sorry for the anxiety and stress caused to the parents of the newborns due to the unfortunate incident. The MOH will work together with KKH to extend all necessary support to the two families. We will also be working with the hospital in their investigations and will review their processes to prevent any recurrence.”
The hospital did not reveal the identities of the families, who have asked for privacy.
Mr Kwek told reporters the two sets of parents were distraught after they learnt of the mix-up. “Both mothers were crying … and the fathers were upset. But they met each other and … were very cordial,” he said. “They were relieved that the ordeal was over but still want to wait for the final tests.”
While the hospital is investigating what happened, Mr Kwek said it was possible that the identifying tag on one of the babies had fallen off, and a wrong tag was put on subsequently. A tag – believed to be the one that came loose – was found yesterday in an empty cot.
Mr Kwek said every newborn at the hospital is tagged with two identifying tags bearing the mother’s name, one on the right ankle which is put on first at the delivery suite, and the second one – on the left ankle – when the baby is taken to the nursery.
When the babies are discharged from the hospital, the nurses are supposed to double-check the tags. However, Mr Kwek said that this might not happen as often as it should and the lapses will be investigated as part of the review.
“At the point of discharge, when the nurses are checking … sometimes if the baby is sleeping, the nurses are a bit reluctant and I think the parents are also reluctant (to have the tags checked) because, to check the ankle, they have to undo the blanket and unwrap the baby, and that unsettles the baby. We suspect that’s what happened – a failure to check,” Mr Kwek said.
Referring to the couple who discovered the mix-up as “Couple B” who brought home “Baby A”, Mr Kwek said Baby A was being breastfed when he was being discharged.
While it was clear that the tag on Baby A’s left ankle “came free”, what happened thereafter is the subject of investigation. “It is possible that the baby had a second tag put on wrongly,” Mr Kwek said.
Couple A are first-time parents, while it was the third child for Couple B. According to Mr Kwek, the other set of parents, Couple A, removed the tags on Baby B without checking them after the family reached home.
Couple A was informed of the mix-up only after a blood test was done to show that Baby A was not Couple B’s child, Mr Kwek said.
Couple A subsequently also underwent blood tests. Both tests showed that the babies’ blood were incompatible with the blood group of the couples that brought them home respectively.
Mr Kwek said that neither of the babies had “distinguishing characteristics”. He added that as newborns, they looked very similar.
On whether any hospital staff will be disciplined, Mr Kwek said the hospital will wait for the investigation to be concluded before taking any action.