Weeks after a 5-month-old infant died during heart surgery in eastern China, an official investigation has found procedural failures and management lapses at the hospital where the operation was performed. 

The findings, published Sunday by the Health Commission of Ningbo in Zhejiang province, found that the surgical team committed errors during the surgery, failed in risk management, did not inform the family of emergencies, and provided inadequate postoperative monitoring. 

As a result, the hospital has removed the chief surgeon from his post and suspended him, along with the anesthesiologist and attending physician of the pediatric ICU, the report said. The hospital’s vice president has also been removed, while its president and Party secretary have received a “demerit” for serious violations and a warning, respectively. 

The report did not disclose the specific medical errors that caused the infant’s death or publicly identify all those responsible.

The infant, Xu Luoxi, died on Nov. 14 after undergoing surgery to repair an atrial septal defect at the Women and Children’s Hospital of Ningbo University. 

In a social media post, the baby’s mother, Deng Rongrong, said the procedure had been described to the family as routine. She wrote that the chief surgeon, surnamed Chen, told them before the operation that it carried a success rate of about 99.5% and was expected to last under three hours. 

Instead, the surgery lasted about seven hours. Deng said the family was informed at around 4 p.m. that the operation “had not gone smoothly… and that the child’s chance of survival was only about 50%.”

About 30 minutes later, Chen told the family that the surgery had been successful and that the child’s “vital signs were stable,” adding that the baby would be transferred to the pediatric intensive care unit for monitoring. Deng later said the family was never informed that a second surgery had been performed during the procedure.

Xu was declared clinically dead around 10 p.m. that night. Three days later, on Nov. 17, authorities announced the formation of an investigation team.

The case has drawn intense public attention, with related hashtags on microblogging platform Weibo amassing more than 2 billion views. Many users have criticized what they see as a lack of transparency surrounding the surgical process and questioned whether the disciplinary measures were sufficient.

Experts have weighed in too. Sun Hongtao, chief pediatric cardiac surgeon at Fuwai Hospital in Beijing, said atrial septal defects are often accompanied by other cardiac abnormalities that can be missed or misdiagnosed, increasing surgical risk. He noted that infants’ conditions can change rapidly during surgery.

Sun added that in practice, delaying surgery until a child is older and heavier can significantly improve safety, stressing that surgical decisions should balance risk with the patient’s overall benefit.

Editor: Marianne Gunnarsson.

(Header image: BSIP/VCG)