Canossa Hospital doctors found guilty of professional misconduct after misdiagnosing man’s HIV test


24th November 2023 – (Hong Kong) In a recent ruling by the Medical Council of Hong Kong, two doctors from Canossa Hospital, Dr. Leung Wai-shun and Dr. Wong Wai On, have been found guilty of professional misconduct for their involvement in a case where a man’s HIV test was misdiagnosed. The patient had conducted a self-test in December 2019, which showed a positive result. Seeking confirmation, he visited Canossa Hospital to undergo an official test.

However, both Dr. Leung and Dr. Wong failed to identify the incorrect arrangement of the “T-lymphotropic virus” (HTLV) test instead of the requested HIV test. They informed the patient that he tested negative for HIV. On Christmas Day of the same month, the patient, experiencing symptoms such as fever, diarrhoea, and rash, sought medical attention at another private hospital. His condition worsened, leading to respiratory failure. After being transferred to a public hospital, the patient was finally diagnosed with HIV.

Following the patient’s complaint, the Medical Council conducted an investigation. The council ruled that Dr. Leung and Dr. Wong had committed professional misconduct. Dr. Leung has been suspended for three months with a two-year probationary period. Moreover, he is required to complete a Continuing Medical Education (CME) course within one year. Dr. Wong received the same penalty as Dr. Leung for failing to detect the misdiagnosis and providing incorrect results to the patient.

The case revealed that the patient had performed an HIV self-test at home, which yielded a positive result. On 7th December, 2019, he visited Canossa Hospital with a friend to seek medical advice. During the consultation with Dr. Leung, the patient expressed the desire to confirm the self-test result through laboratory testing. Dr. Leung’s medical record indicated “HIV tests,” but instead, he instructed the staff to conduct “HTLV tests.”

On 12th December, the test results showed a negative result for “HTLV-I/II.” Dr. Leung reviewed the test results on 14th December and failed to identify the incorrect testing procedure. He arranged for a nurse to inform the patient of the negative result.

The patient learned about the results on December 16 and followed up at the outpatient department on 21st December, where he met with Dr. Wong. Both the patient and Dr. Wong were aware of the positive self-test results, leading them to conduct further testing at the hospital. Based on Dr. Wong’s submission to the Medical Council, he believed that he was reviewing the report for HIV testing and subsequently informed the patient of a negative result, failing to recognize that it was, in fact, the result of the HTLV test.

However, on Christmas Day, just four days later, the patient experienced fever, diarrhoea, and rash, prompting him to seek medical attention at the Hong Kong Baptist Hospital. His respiratory condition deteriorated rapidly, leading to respiratory failure on 27th December, requiring intubation and the use of a ventilator. He was transferred to Queen Elizabeth Hospital on 29th December, where he was finally diagnosed with HIV. The patient lodged a complaint with the Medical Council in 2021.

The ruling by the Medical Council’s disciplinary committee emphasised the severity of the accusations. Despite the positive result from the self-test, the hospital’s tests indicated a negative result for HIV. Dr. Leung and Dr. Wong were expected to exercise extreme caution when interpreting the results, but their actions fell short of professional standards.