Report of the Select Committee to
inquire into the handling of
the Severe Acute Respiratory Syndrome outbreak by
the Government and the Hospital Authority
July 2004

TABLE OF CONTENTS

CHAPTERS		Page
1	Introduction	1 - 16
2	The case of AA in the Kwong Wah Hospital	17 - 26
3	Gathering of information/intelligence about epidemic of infectious diseases in the Mainland and strategy/ contingency plan of the Hospital Authority for dealing with a large-scale outbreak of an infectious disease	27 - 37
4	The M Hotel Cluster	38 - 42
5	Quarantine and Prevention of Disease Ordinance (Cap. 141)	43 - 64
6	Outbreak at the Prince of Wales Hospital	65 - 106
7	Outbreak at the Alice Ho Miu Ling Nethersole Hospital	107 - 121
8	Outbreak at the Amoy Gardens	122 - 148
9	Outbreak at the United Christian Hospital	149 - 160
10	Outbreak at the Princess Margaret Hospital	161 - 187
11	Outbreak at the Tai Po Hospital	188 - 200
12	Outbreak at the Tuen Mun Hospital	201 - 212
13	Infection control measures in hospitals	213 - 232
14	Command structure of the Government and the Hospital Authority in the handling of the SARS outbreak	233 - 248
15	Conclusions and Recommendations	249 - 261
Signatures of members of the Select Committee		263

Appendices
Appendix I	Practice and procedure of the Select Committee	267 - 279
Appendix II	Lists of organizations and individuals which/who made submissions to the Select Committee	280 - 281
Appendix III	Schedule of hearings and names of witnesses	282 - 291
Appendix IV	Notes of meeting on 22 May 2004 between the Chief Executive and members of the Select Committee	292 - 317
Appendix V	Pseudonyms used in the Report	318
Appendix VI	A chronology of important events and activities during the SARS outbreak at the Prince of Wales Hospital	319 - 322
Appendix VII	13 New Territories East Cluster guidelines issued by Dr Donald LYON between 14 March and 31 March 2003 for hospitals in the New Territories East Cluster	323
Appendix VIII	Other issues raised at the meeting on 5 April 2003 attended by Dr Stephen NG Kam-cheung, Dr YEOH Eng-kiong, Dr Trevor Maxwell ELLIS, Dr Thomas TSANG Ho-fai, Mr YUEN Ming-chi, Dr LO Su-vui and Dr Paul SAW Thian-aun	324 - 332
Appendix IX	Index patients of Wards 3DR, 4BR and 4DR in the Tai Po Hospital	333
Appendix X	Questionnaire on "Measures relating to Personal Protective Equipment during Outbreak of Severe Acute Respiratory Syndrome"	334 - 339
Appendix XI	Analysis of responses to the questionnaire on "Measures relating to Personal Protective Equipment during Outbreak of Severe Acute Respiratory Syndrome"	340 - 362
Lists of written evidence/documents
A	Evidence/documents provided by the Administration and related persons	366 - 381
B	Evidence/documents provided by the Hospital Authority and related persons	382 - 399
C	Evidence/documents provided by witnesses and other persons	400 - 407
D	Evidence/documents provided by universities, medical professional bodies/individuals and other parties	408 - 411
Minutes of proceedings		415 - 434

Minutes of evidence of public hearings

Table of Contents

No.	Date of public hearing	Witness
1	13 December 2003	Miss YANG Siu-fan Registered Nurse, Kwong Wah Hospital
		Dr CHOW Kin-wa Medical Officer, Accident and Emergency Department, Kwong Wah Hospital
		Dr WU Chun-wah Consultant, Accident and Emergency Department, Kwong Wah Hospital
		Dr LUK Che-chung Hospital Chief Executive, Kwong Wah Hospital
2	16 December 2003	Dr Melissa HO (Khin Khin Tint) Infection Control Officer, Kwong Wah Hospital
		Dr WATT Chi-leung Consultant (Director), Intensive Care Unit,Kwong Wah Hospital
		Dr York CHOW Yat-ngok Cluster Chief Executive (Hong Kong West)/Hospital Chief Executive, Queen Mary Hospital
3	20 December 2003	Professor HO Pak-leung Associate Professor, Division of Infectious Diseases, Department of Microbiology, Faculty of Medicine,The University of Hong Kong
		Professor Kenneth TSANG Wah-tak Associate Professor, Specialty Division of Respiratory and Critical Care Medicine, Department of Medicine, Faculty of Medicine, The University of Hong Kong
		Dr SETO Wing-hong Chief of Service, Department of Microbiology,Queen Mary Hospital/Infection Control Officer,Hong Kong West Cluster
4	6 January 2004	Ms KWOK Lai-yin Deputy Ward Manager (Nurse Specialist),Intensive Care Unit, Kwong Wah Hospital
		Dr TSANG Hin-hung Senior Medical Officer, Intensive Care Unit,Kwong Wah Hospital
		Dr Andrew YIP Wai-chun Chief of Service, Department of Surgery,Kwong Wah Hospital
		Dr LIU Shao-haei Senior Executive Manager (Professional Services), Hospital Authority (Convenor of the Central Committee on Infection Control (named the Task Force on Infection Control before 4 March 2003) and the Working Group on Severe Community-Acquired Pneumonia of the Head Office of the Hospital Authority) (Dr LIU Shao-haei has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Professor YUEN Kwok-yung Head/Clinical Professor (Chair of Infectious Diseases), Department of Microbiology, Faculty of Medicine,The University of Hong Kong
5	10 January 2004	Dr TSE Lai-yin, JP Consultant Community Medicine in-charge, Disease Prevention and Control Division, Department of Health
		Professor Joseph SUNG Jao-yiu Chairman, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong/Chief of Service, Department of Medicine and Therapeutics, Prince of Wales Hospital (Professor Joseph SUNG Jao-yiu has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
6	12 January 2004	Dr Margaret CHAN FUNG Fu-chun Former Director of Health
7	13 January 2004	Dr Margaret CHAN FUNG Fu-chun Former Director of Health
8	17 January 2004	Dr FUNG Hong, JP Cluster Chief Executive (New Territories East)/Hospital Chief Executive, Prince of Wales Hospital
9	20 January 2004	Dr Donald James LYON Consultant, Department of Microbiology,Prince of Wales Hospital/Infection Control Officer, New Territories East Cluster
		Mr Albert NG Hon-yui Department Operations Manager, Department of Medicine and Therapeutics, Prince of Wales Hospital
		Mr CHAN Man Deputizing Nursing Officer, Department of Medicine and Therapeutics, Prince of Wales Hospital
		Dr David HUI Shu-cheong Head of Division of Respiratory Medicine/Associate Professor, Department of Medicine and Therapeutics, Faculty of Medicine,The Chinese University of Hong Kong
10	31 January 2004	Professor Sydney CHUNG Sheung-chee Dean, Faculty of Medicine, The Chinese University of Hong Kong
11	3 February 2004	Dr LUI Siu-fai Service Director (Risk Management and Quality Assurance), New Territories East Cluster
		Professor WONG Tze-wai Department of Community and Family Medicine, Faculty of Medicine, The Chinese University of Hong Kong
		Dr Louis CHAN Yik-si Medical Officer, Department of Obstetrics and Gynaecology/Officer-in-charge, Disease Control Centre, Prince of Wales Hospital
		Ms CHAN Kit-hoi Department Operations Manager, Department of Medicine, Alice Ho Miu Ling Nethersole Hospital
		Ms TSANG Sou-wah General Manager (Nursing), Alice Ho Miu Ling Nethersole Hospital
		Ms Lily CHUNG Choy-lan Service Director (Nursing), New Territories East Cluster
12	7 February 2004	Dr CHAN Hok-sum Consultant Physician, Department of Medicine,Alice Ho Miu Ling Nethersole Hospital
		Dr Raymond CHEN Chung-i Hospital Chief Executive, Alice Ho Miu Ling Nethersole Hospital
		Dr AU Tak-kwong Community Physician (New Territories East), Department of Health
		Dr Thomas TSANG Ho-fai Consultant Community Medicine (Communicable Disease), Disease Prevention and Control Division, Department of Health
13	10 February 2004	Dr KO Wing-man, JP Director (Professional Services and Public Affairs), Hospital Authority (Dr KO Wing-man, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
14	14 February 2004	Dr KO Wing-man, JP Director (Professional Services and Public Affairs), Hospital Authority (Dr KO Wing-man, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
15	17 February 2004	Dr LEUNG Pak-yin, JP Deputy Director of Health
16	21 February 2004	Ms CHIU Wing-mui Former Ward Manager of Ward 12A,United Christian Hospital
		Ms CHAN Yuet-kwai General Manager (Nursing), United Christian Hospital
		Dr LAI Wai-man Infection Control Officer, United Christian Hospital
		Ms CHAN Nim-chi Department Operations Manager, Department of Medicine and Geriatrics, United Christian Hospital
		Dr Edward LEUNG Man-fuk Chief of Service, Department of Medicine and Geriatrics, United Christian Hospital
17	24 February 2004	Dr LAU Fei-lung Chief of Service, Accident and Emergency Department, United Christian Hospital
		Dr TSE Chun-yan Cluster Chief Executive (Kowloon East)/Hospital Chief Executive, United Christian Hospital
		Ms Winnie CHAN Kwan-ying Department Operations Manager, Intensive Care Unit, Princess Margaret Hospital (Ms Winnie CHAN Kwan-ying has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
		Ms Adela LAI Shuet-fun General Manager (Nursing), Princess Margaret Hospital (Ms Adela LAI Shuet-fun has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
18	28 February 2004	Dr Thomas SO Man-kit Senior Medical Officer, Infectious Disease Team, Department of Medicine and Geriatrics, Princess Margaret Hospital (Dr Thomas SO Man-kit has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr YU Wai-cho Consultant Physician, Department of Medicine and Geriatrics, Princess Margaret Hospital (Dr YU Wai-cho has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr NG Tak-keung Infection Control Officer, Princess Margaret Hospital (Dr NG Tak-keung has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr Stephen NG Kam-cheung
19	2 March 2004	Dr YAN Wing-wa Consultant, Intensive Care Unit,Princess Margaret Hospital (Dr YAN Wing-wa has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr Thomas Anthony BUCKLEY Chief of Service, Intensive Care Unit,Princess Margaret Hospital
		Dr Matthew TONG Kwok-lung Chief of Service, Department of Medicine and Geriatrics, Princess Margaret Hospital (Dr Matthew TONG Kwok-lung has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr Lily CHIU Lee-lee Cluster Chief Executive (Kowloon West)/Hospital Chief Executive, Princess Margaret Hospital (Dr Lily CHIU Lee-lee has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
20	6 March 2004	Dr William HO Shiu-wei, JP Chief Executive, Hospital Authority (Dr William HO Shiu-wei, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
21	9 March 2004	Dr LEONG Che-hung, GBS, JP Chairman, Hospital Authority (Dr LEONG Che-hung, GBS, JP has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr Sarah LIAO Sau-tung, JP Secretary for the Environment, Transport and Works
		Professor Joseph SUNG Jao-yiu Chairman, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong/Chief of Service, Department of Medicine and Therapeutics, Prince of Wales Hospital (Professor Joseph SUNG Jao-yiu has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
22	13 March 2004	Dr YEOH Eng-kiong, JP Secretary for Health, Welfare and Food
23	16 March 2004	Dr YEOH Eng-kiong, JP Secretary for Health, Welfare and Food
24	20 March 2004	Dr LIU Shao-haei Senior Executive Manager (Professional Services), Hospital Authority (Convenor of the Central Committee on Infection Control (named the Task Force on Infection Control before 4 March 2003) and the Working Group on Severe Community-Acquired Pneumonia of the Head Office of the Hospital Authority) (Dr LIU Shao-haei has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr CHEUNG King-on Consultant in-charge, Intensive Care Unit,Caritas Medical Centre
		Dr HUI Yim-wo Senior Medical Officer, Department of Paediatrics, Princess Margaret Hospital
25	23 March 2004	Dr TAM Cheuk-yin Consultant Physician, Department of Medicine and Geriatrics, Tuen Mun Hospital (Dr TAM Cheuk-yin has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr LEE Tsun-woon Chief of Service, Department of Anaesthesia and Intensive Care, Tuen Mun Hospital (Dr LEE Tsun-woon has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr QUE Tak-lun Infection Control Officer, Tuen Mun Hospital (Dr QUE Tak-lun has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr Simon CHOW Liang Chief of Service, Department of Medicine and Geriatrics, Tuen Mun Hospital (Dr Simon CHOW Liang has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Dr CHEUNG Wai-lun Cluster Chief Executive (New Territories West)/ Hospital Chief Executive, Tuen Mun Hospital (Dr CHEUNG Wai-lun has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
26	27 March 2004	Dr YEOH Eng-kiong, JP Secretary for Health, Welfare and Food
27	3 April 2004	Mr LAM Woon-kwong, GBS, JP Director of the Chief Executive's Office
28	17 April 2004	Mr LAM Woon-kwong, GBS, JP Director of the Chief Executive's Office
29	20 April 2004	Dr YEOH Eng-kiong, JP Secretary for Health, Welfare and Food
		Mr Boris TO Hing-kuen Ward Manager, Tai Po Hospital (Mr Boris TO Hing-kuen has declined to make any comments on or propose any corrections to this verbatim transcript of his evidence)
		Ms Maria CHUI Yeuk-ping Department Operations Manager,Department of Medicine and Geriatrics, Shatin Hospital (Ms Maria CHUI Yeuk-ping has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
		Ms Helena LI Yuk-lin General Manager (Nursing), Tai Po Hospital (Ms Helena LI Yuk-lin has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
		Dr TUNG Sau-ying Hospital Chief Executive, Tai Po Hospital (Dr TUNG Sau-ying has declined to make any comments on or propose any corrections to this verbatim transcript of her evidence)
30	24 April 2004	Dr LO Su-vui Head, Research Office, Health, Welfare and Food Bureau
		Dr Paul SAW Thian-aun
		Dr Trevor Maxwell ELLIS Senior Veterinary Officer (Veterinary Laboratory), Veterinary Laboratory Division,Agriculture, Fisheries and Conservation Department
		Mr YUEN Ming-chi Pest Control Officer-in-charge, Pest Control Advisory Section, Food and Environmental Hygiene Department
		Dr Thomas TSANG Ho-fai Consultant Community Medicine (Communicable Disease), Disease Prevention and Control Division, Department of Health

The above post titles were those held by the witnesses at the time when they attended the hearings of the Select Committee