A 64-year-old man who had undergone a kidney transplant and was a cancer survivor died a few days after a procedure to drain abnormal fluid accumulated in his abdominal cavity, a coroner's inquest heard.
Freelance designer Alan Kong Ban Huat was later found to have sepsis. He suffered from a clotting disorder - coagulopathy - and contracted hepatitis C while warded at the Singapore General Hospital (SGH).
He is one of the seven patients for whom hepatitis C, likely acquired at SGH, was identified as a likely "contributory" factor in their deaths. The seven cases were identified by an independent review committee convened by the Ministry of Health.
In Mr Kong's case, senior consultant forensic pathologist Paul Chui found that he died primarily because of a surgical injury rather than from contracting hepatitis C.
Mr Kong suffered from several medical conditions including hypertension, post-transplant diabetes mellitus and osteoporosis.
Mr Kong was first admitted to SGH on May 16, 2015, with fungal infection in the lower limb tissue.
When he was admitted a second time to SGH in June 2015, he was found to have ascites, an accumulation of fluid in the abdomen. He also had bleeding in the liver, kidney cysts and hepatitis C, and was suspected to have had an infection, resulting in sepsis.
On June 25, the day after a procedure to drain the abdominal fluid, he collapsed and had to be resuscitated due to low blood pressure and haemoglobin levels.
Despite intervention, Mr Kong remained critically ill and died at 10.38pm on June 29 that year.
In his findings, State Coroner Marvin Bay said there was no basis to suspect foul play.
While hepatitis C was among Mr Kong's maladies, the coroner said it was not the main cause of death.
Fungal sepsis resulted in his multiple organ failure and he had suffered massive internal bleeding consistent with vascular damage, which was further complicated by his clotting disorder.
Mr Kong's death was caused by "traumatic damage" which occurred during the procedure to drain abdominal fluid. The coroner found Mr Kong's death to be the result of an "unfortunate medical misadventure".
SGH has since put in place a series of measures to minimise the risk of hepatitis C transmissions.
The measures include a mandatory annual online competency assessment for all clinical staff, and daily audits of safe injection practices and compliance with hand and environmental hygiene.
In addition, the use of multi-dose vials for injection has been discontinued since June 29, 2015.
The hospital has also improved its system of pathogen surveillance, and created a nerve centre to strengthen its response to possible outbreaks.