MOH probing erroneous 4th Covid-19 vaccine dose given to 103-year-old nursing home resident

SINGAPORE — The Ministry of Health (MOH) is looking into the death of a 103-year-old nursing home resident who, in a case of "mistaken identity", was wrongly administered with a fourth dose of a Covid-19 vaccine by a mobile vaccination team.

Preliminary findings by the ministry showed that the vaccine was erroneously administered due to "possible irregularities in vaccination procedures and poor communication between the nursing home and the medical service provider handling the vaccination", MOH said in a statement on Friday (Feb 4) evening.

An autopsy ordered by a coroner found that the main cause of the woman's death was pneumonia, with other contributing factors being cerebral infarction (or stroke) and coronary artery disease, which are natural disease processes common in seniors, MOH added.

"The coroner has not determined whether these causes of death were linked to the vaccination." 

WHAT HAPPENED

In its statement, MOH said that the woman, who is a resident of Econ Healthcare – Chai Chee Nursing Home, had already received three doses of a Covid-19 vaccine.

She was wrongly given a fourth shot on Dec 13 last year by a mobile team from PanCare Medical Clinic.

In response to TODAY's queries, Econ Healthcare said that the mistake was discovered about five minutes after the vaccine was administered.

The teams from Econ Healthcare and PanCare Medical Clinic attended to the woman and extended the post-vaccination observation time. 

"The resident had no adverse reaction during that time," Econ Healthcare said.

A few days later on Dec 16, she was admitted to Changi General Hospital for pneumonia and hyponatremia, a condition where sodium levels in the blood are lower than normal, usually due to too much water in the body. The woman was later diagnosed to have suffered a stroke as well.

She died on Jan 10 this year. 

"This is the first case of mistaken identity leading to erroneous vaccination by a mobile vaccination team in over 152,000 vaccinations to date," MOH said.

The ministry said that it takes a serious view of this incident and is carrying out a thorough investigation. It expects the investigations to conclude this month.

In response to TODAY's queries, Pancare Medical Clinic said it has submitted its account of what happened to MOH's investigation team. "We would like to wait for the completion of the investigation before releasing the findings," it said.

Besides the mobile vaccination team which it has run for the past eight to nine months, it also operates a vaccination centre and a vaccination clinic under the Public Health Preparedness Clinic scheme.

DELAYED ANNOUNCEMENT

MOH also said that it had planned to announce this incident in December last year, but had delayed doing so because the woman's family had asked to withhold details, which could have led to the identification of the deceased.

"We have since consulted the family further and are releasing the information to provide clarity on the incident."

Econ Healthcare Group and PanCare Medical Clinic have funded the the woman's hospital bill "as a goodwill gesture", the ministry said.

Econ Healthcare has also been in contact with the woman's family to render support to them.

Econ Healthcare and PanCare Medical Clinic have reviewed their processes to prevent a recurrence, MOH said.

The Agency for Integrated Care, which facilitates vaccinations in nursing homes, has reminded all nursing homes to ensure proper communications with the mobile vaccination teams when vaccination takes place.

"MOH has also reminded all mobile vaccination teams to perform independent identity verification and authentication before administering any vaccination," the ministry added.