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Chemo underdosing bungle could have been avoided, inquest finds

Email Deputy coroner hands down findings into bungled chemotherapy treatment By Leah MacLennan and Camron Slessor

Posted March 22, 2019 12:42:01

Anne Pinxteren Photo: Anne Pinxteren (left) was one of 10 patients who received the incorrect dose of chemotherapy. (Supplied) Related Story: Doctors lose 'heartless' bid to shut down chemo underdosing coronial inquest Related Story: "We won't be crushed": Chemo underdosing victim vows to fight on Related Story: SA chemo bungle patients' treatments may have been compromised, inquest told Map: Adelaide 5000

An inquest has found achemotherapy underdosing bungle could have been avoided if protocols in place at the Queen Elizabeth Hospital (QEH) had been adopted at the Flinders Medical Centre (FMC) and the Royal Adelaide Hospital (RAH).

Key points:

  • Four patients died after the bungled chemotherapy treatment
  • The deputy coroner handed down his findings into the deaths
  • A surviving victim said the report showed clinicians were behaving like "cowboys"

Deputy coroner Anthony Schapel investigated the deaths of four cancer patients who received incorrect chemotherapy treatment in 2014 and 2015.

Christopher McRae, 67, Anne Pinxteren, 76, Bronte Higham, 68, and Carol Bairnsfather, 70, died after they were underdosed during chemotherapy treatment at the RAH and FMC.

The dosage errorled to an independent review, which found that a series of significant clinical governance failures at the RAH's haematology unit led to 10 cancer patients receiving incorrect chemotherapy doses.

Over a six-month period in 2014 and 2015, patients at the RAH and FMC were given one dose of the chemotherapy drug Cytarabine a day, when they should have been given two.

Coroner Anthony Schapel Photo: Deputy SA coroner Anthony Schapel handed down his findings today. (Emma Pedler: ABC)

In his findings, Mr Schapel said it was odd that different hospitals had their own protocol systems.

He found the errors could have been avoided if the RAH and FMC followed the QEH in adopting the "eviQ chemotherapy protocol system".

He also said there was a clear need for pharmacists to be involved.

"To my mind there is a clear need for uniformity as between the chemotherapy prescription systems across the board in South Australia," he said in his findings.

"Another matter that arises from this inquest is that there is a clear need for pharmacists to be involved in the chemotherapy protocol alteration and promulgation system.

"It so happens that at both the RAH and the FMC pharmacists were either instrumental in identifying the error in the case of the RAH, or in the case of the FMC at least instrumental in identifying an issue, an issue that clearly should have been resolved in favour of what the pharmacist had suspected was an error."

SA Health reporting system slammed

Mr Schapel also slammed SA Health's incident reporting system following the bungle, and said it did not work across the state.

He recommended the system be abandoned and replaced with a new system that reports adverse events immediately to every hospital's chief executive and the head of SA Health.

He found the system was initially not used at all following chemotherapy underdosing at the RAH and later failed to prevent further incidents at FMCs.

Andrew Knox, who was also underdosed and nearly died after he relapsed, said the coroner's findings were profound and the recommendations were what he had hoped to see.

He said while thecoroner could not find that the underdosing caused the deaths, he also could not say that it did not.

Andrew Knox sits in a wheelchair looking over the deputy coroner's findings into the chemotherapy bungle Photo: Surviving victim Andrew Knox reads over the findings today. (ABC News: Leah MacLennan)

"The coroner was unable to find that the [underdosing] necessarily caused relapses or shortening of life, but on the other hand he couldn't say that it didn't, so it was an open verdict on that," he said.

"I guess none of us really expected that there would have been a finding that the underdosing caused us to die and relapse."

Clinicians were behaving like 'cowboys'

Mr Knox said the amount of work that had gone into the inquest had been immense and the findings had shown how let down the public, and the victims had been.

"It just shows that the diversity of clinicians at the QEH were behaving in a highly professional way, whereas the FMC and RAH were behaving as cowboys when lives were at risk," he said.

"It now relies on the government of the day and SA Health to join the dots to make sure that those people in administration who let us and the public down, don't do it again.

"Part of that, a new safety learning system, [and] safety reporting system is a foundation that they can work from."

Mr Knox said his health was still suffering from his chemo underdosing ordeal and he believed it could have been prevented.

"I'm in a wheelchair because I've had the first of two rather painful hip replacements from all the steroid damage from all the prolonged chemo," he said.

"I would suggest that had I been treated correctly, I wouldn't be going through that pain."

Kym Higham, the son of Bronte Higham who died in 2016, said the findings were not surprising, but it did bring some closure.

"I guess the big thing for my family and I think other families as well is the recommendations that will come out of it, just to try and ensure that other families don't have to go through the same thing," he said.

SA Premier Steven Marshall said the State Government would take its time before outlining its thoughts on the findings.

"The chemotherapy dosing bungle was a very dark chapter in our state's history, it was another shameful chapter in the former Labor government's administration," he said.

"Today is a day where we think about the victims of that tragedy, we will look very carefully at what the coroner has recommended, and we'll be giving our response in a speedy and timely way."

Topics: health, law-crime-and-justice, doctors-and-medical-professionals, cancer, adelaide-5000, bedford-park-5042, sa

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