The Ministry of Health (MOH) is investigating a case of a 103- year-old nursing home resident who was erroneously administered with a fourth dose of Covid-19 vaccine and subsequently passed away.
According to an autopsy, the main cause of death was pneumonia, with contributing factors of cerebral infarction (or stroke) and coronary artery disease.
The ministry pointed out in its statement that the latter two are "natural disease processes common in seniors".
According to MOH, the Coroner has not determined whether these causes of death were linked to the vaccination.
What happened?
The resident had previously received three doses of Covid-19 vaccine, and was erroneously given a fourth shot on December 13, 2021.
The fourth dose was administered by a mobile vaccination team from PanCare Medical Clinic.
On December 16, 2021, the resident was admitted to Changi General Hospital for pneumonia and hyponatremia (abnormally low concentration of sodium in the blood).
She was subsequently also diagnosed to have suffered a stroke. She passed away on January 10, 2022.
Investigations expected to conclude in February 2022
The health ministry said:
"MOH takes a serious view of this incident and is carrying out a thorough investigation under Regulations 14A(1) and 36(1) of the Private Hospitals and Medical Clinics Regulations."
It added that it expects the investigations to conclude in February 2022.
Preliminary investigations found 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".
This is the first case of mistaken identity leading to erroneous vaccination by a mobile vaccination team in over 152,000 vaccinations to date, the ministry added.
Hospital bill co-funded by residential home and service provider
MOH also said that while it had planned to announce this incident in December 2021, the family of the late resident requested to withhold details which could have led to the identification of the latter.
As a goodwill gesture, the ECON Healthcare Group and PanCare Medical Clinic have co-funded the resident’s hospital bill. The former has also been in contact with the resident’s family to render support to them.
Both the residential home and the medical service provider have reviewed their processes to prevent a recurrence, said MOH.
MOH has also reminded all mobile vaccination teams to perform independent identity verification and authentication before administering any vaccination.
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