XN000022-1991-12-05 — Page 3

2

THE OBJECTIVES OF THE STUDY WILL BE:

*

TO REVIEW:

THURSDAY, DECEMBER 5, 1991

IN

THE SAFETY SYSTEMS AND PROCEDURES PRESENTLY PRACTISED THE MEDICAL GAS MANUFACTURING INDUSTRY IN HONG KONG, TAKING INTO ACCOUNT ALL EXISTING CONTROLLING LEGISLATION AND THE RESULTANT EFFECTIVENESS;

THE SAFETY MEASURES AT THE END-USERS' PREMISES;

THE CONTROL OF SAFETY AND QUALITY ASPECTS IN THE MANUFACTURE, FILLING, DELIVERY AND HANDLING OF SUCH GASES IN BULK OR PORTABLE CONTAINERS FROM THE POINT OF PRODUCTION RIGHT UP UNTIL THEIR ADMINISTRATION ΤΟ PATIENTS;

THE MEDICAL GAS MANUFACTURING INDUSTRY IN HONG KONG AND TO RECOMMEND MEASURES TO ENSURE A CONTINUOUS AND SAFE SUPPLY TO THE LOCAL MARKET; AND

ΤΟ RECOMMEND PRACTICABLE MEASURES, WHICH MAY INCLUDE AMENDMENTS то EXISTING LEGISLATION, ENACTMENT OF NEW LEGISLATION AND ADOPTION OF RELEVANT INTERNATIONALLY RECOGNISED STANDARDS TO ENHANCE, WHERE NECESSARY, THE CURRENT STANDARD OF SYSTEMS AND PROCEDURES ON THE CONTROL OF SAFETY AND QUALITY ASPECTS IN THE MANUFACTURE, FILLING, DELIVERY AND HANDLING OF SUCH GASES.

MR CHOW SAID AN INTERDEPARTMENTAL WORKING PARTY WAS FORMED TO INVESTIGATE THE INCIDENT INVOLVING A NITROUS OXIDE CYLINDER AT THE CARITAS MEDICAL CENTRE IN JULY LAST YEAR.

THE WORKING PARTY COMPRISED REPRESENTATIVES FROM THE FIRE SERVICES DEPARTMENT, ELECTRICAL AND MECHANICAL SERVICES DEPARTMENT, HOSPITAL SERVICES DEPARTMENT, DEPARTMENT OF HEALTH, LABOUR DEPARTMENT, INDUSTRY DEPARTMENT AND GOVERNMENT LABORATORY.

MR CHOW SAID NEITHER THE WORKING PARTY NOR A SEPARATE POLICE INVESTIGATION WAS ABLE TO DETERMINE THE CAUSE OF THE INCIDENT.

"HOWEVER, ITS FINDINGS SUGGESTED THE POSSIBILITY OF NEGLIGENCE WHILE THERE STILL REMAINED THE POSSIBILITY OF A MALICIOUS ACT.

"AS A RESULT OF THE FINDINGS OF THE INVESTIGATION, THE WORKING PARTY PROPOSED MORE STRINGENT PROCEDURES TO CONTROL THE HANDLING OF MEDICAL GASES IN ADDITION TO THOSE ARISING FROM THE PREVIOUS INCIDENT WHICH OCCURRED AT THE CANOSSA HOSPITAL IN 1989.

"THESE INCLUDE IMPROVEMENTS TO PROCEDURES FOR PRODUCTION AND HANDLING, MORE SUPERVISION AND TRAINING OF STAFF, SEPARATION OF PRODUCTION AND STORAGE AREAS, LABELLING AND SEALING OF GAS CONTAINERS OR CYLINDERS, HE SAID.

10

AND

MR CHOW SAID THE MANAGEMENT OF THE HONG KONG OXYGEN ACETYLENE COMPANY LTD (HKO) AGREED TO IMPLEMENT THE RECOMMENDATIONS ARISING FROM THE WORKING PARTY REPORTS ON BOTH INCIDENTS.

/HE SAID