Deputy Coroner receives findings on culpability of clinicians in the chemotherapy underdosing scandal
THREE senior haematologists at two hospitals failed to raise the alarm after discovering that seriously ill leukaemia patients were only receiving half the recommended chemotherapy dose.
- Two medicos stood down over chemo underdosage scandal
- Chemo bungle victim Andrew Knox trying stem cell treatment
- Coroner’s inquest begins as fourth victim dies
- Brave chemotherapy bungle victim Bronte Higham dies
THREE senior haematologists at two hospitals failed to raise the alarm after discovering that seriously ill leukaemia patients were only receiving half the recommended chemotherapy dose.
Two RAH haematologists, Associate Professor Ian Lewis and Dr Agnes Yong are understood to have been stood down earlier this month by SA Health over their inaction.
Their conduct it still under investigation by the Medical Board of Australia (MBA) which, as an ultimate sanction, could deregister them.
A third doctor who failed to act, Dr Ashanka Beligaswatte, a haematology consultant at FMC, was found to have breached the patient safety code of conduct but was not subject to further regulatory action.
Findings on the culpability of 11 clinicians who were reported by SA Health chief executive Vickie Kaminski to the regulatory body AHPRA (Australian Health Practitioner Regulation Agency), which supports the MBA, were in a letter to her on May 10.
The letter, marked Private and Confidential, was tendered as evidence on Friday to the Deputy Coroner, Anthony Schapel, with AHPRA’s permission during a directions hearing.
Mr Schapel, who is inquiring into the deaths of four underdosed patients, Chris McRae, Johanna Pinxteren, Bronte Higham and Carol Bairnsfather, will set aside at least three weeks in November for the doctors and pharmacists to take the stand.
The inquest proper will commence on September 18 for a week of medical evidence before breaking until November.
Eight of the clinicians who were reported, were not subject to further action, including Associate Professor Peter Bardy, who was head of cancer at RAH until he resigned last year, and FMC Associate Professor Bryone Kuss, who was the first to lodge a safety report 23 days after the error was discovered.
Factual findings by the MBA included that a FMC pharmacist, Ms Kailin Teh, picked up the typographical error that altered “twice daily” to “daily” soon after it was made but she was fobbed off by Dr Beligaswatte who failed to check any further.
“Ms Teh noticed the dose discrepancy between A/Prof Lewis’ email and the amended RAH protocol,” the MBA reported.
“She queried this with Dr Beligaswatte but was incorrectly informed that the once daily dose was correct.”
The error only came to light months later in January, 2015, when Dr Yong wrote a prescription requesting the drug twice daily, and it was queried by an RAH pharmacist using the incorrect protocol.
When the mistake was confirmed at the RAH on January 19, “Dr Yong did not mention the error to anyone else”, the MBA reported.
One of the pharmacists who spoke to her about it came away satisfied Dr Yong would “sort it”, but no report was lodged.
Three days later, leukaemia patient Andrew Knox was given the incorrect dose.
Speaking from a Melbourne hospital where he is slowly recovering from a stem cell transplant after his leukaemia returned, Mr Knox said he was disgusted inquiries had taken this long.
“I am completely shattered it has taken so long to get to this tiny fragment of common sense,” he said.