Chemo blunder inquest findings: SA hospital safety systems failed, should have had Royal Commission, says Deputy Coroner

Arrogant doctors who didn’t read emails, a specialist who did nothing when confronted with his mistake and missed chances were behind the underdosing of 10 seriously ill cancer patients, four of whom died.

• June 2018: Chemo victim wants doctors held to account
• May 2018: Chemotherapy underdosing inquest must continue: Crown
• May 2018: Chemo doc dumps bid to halt underdosing inquest
• Feb 2017: Fourth victim died during the course of the inquest
• Nov 2017: Inquest opens detailing how chemo bungle happened
• June 2015: How The Advertiser first broke this tragic story

Arrogant, self-important doctors who didn’t bother reading emails, a specialist who froze and did nothing when confronted with his mistake and a series of spectacular missed opportunities were behind the underdosing of 10 seriously ill cancer patients undergoing chemotherapy in SA in 2014 and early 2015, four of whom died.

READ BELOW: Timeline to a tragedy

In the long-awaited Coroner’s report into the deaths of Joanna Pinxteren, Christopher McRae, Bronte Higham and Carol Bairnsfather, Deputy Coroner Anthony Schapel was unable to conclude that any of them died because they were underdosed.

Specialist evidence described treating acute myeloid leukaemia as “a scary business” in which attention to detail was very important while catch-up chemotherapy in some cases months later was “winging it” and likely to be less effective.

Mr Schapel found that in the case of the four deaths, and of surviving patient Andrew Knox who relapsed but had a stem cell transplant, it was not possible to conclude their remission was shortened or their survival was significantly reduced.

However, with Mr Knox who conceivably may have been cured if his first treatment had succeeded, there was “grave suspicion” that it acted to his detriment.

Andrew Knox speaks to the media after Deputy Coroner Anthony Schapel handed down his findings chemo underdosing scandal. Picture: AAP / Kelly Barnes

Learning of the mistake in itself would have left them all wondering how it affected their outcome, Mr Schapel found.

“This in and of itself is a truly dreadful thing,” he said.

After seven investigations which began with the Vilis Marshall Report and included the Select Committee inquiry which slammed clinical governance within SA Health, Mr Schapel said the underdosing should have been dealt with by a Royal Commission, which Health Minister Stephen Wade did not rule out.

Mr Schapel said in his view only a Royal Commission with proper resources had the ability to thoroughly inquire not only into the causes of the four deaths but also the underdosing of the remaining six, most if not all are thought to have relapsed and are under treatment.

“It goes without saying that a commission of inquiry would have been furnished with greater resources than Court could possibly muster,” he said.

Mr Wade said a Royal Commission would need wider consideration by the Government, as did possible changes to the Coroner’s Act.

Deputy Coroner Anthony Schapel.

“We need to make sure that we maximise the opportunity for the Coroner’s Court to fulfil its functions and see how that might interact with other forms of investigations,” he said.

Individual doctors came out of the report badly, including the then RAH head of haematology, Professor Ian Lewis, and a senior haematologist Dr Agnes Yong, both of whom were stood down in May 2017 by SA Health following recommendations by the regulatory professional body AHPRA.

Appearing in the Coroner’s Court in late 2017, Assoc Prof Lewis said when he discovered the mistake he was stressed and did nothing.

“Like a kangaroo caught in the headlights … I froze, I just did not know what to do,” he said.

Mr Schapel said instead he should have found out more about who was affected, established whether patients in other hospitals were also underdosed, notified his manager, lodged a Safety Learning System report and told the patients.

He rejected as unacceptable the excuse offered by Dr Yong, that she said was from a patriarchal Chinese family where one does not tell one’s seniors what to do.

“Clearly this was unacceptable,” Mr Schapel said.

Mr Schapel said the Safely Learning Systems relied on to fix mistakes had failed and should be replaced. He also called for a statewide electronic prescription system for all haematology departments, although even this was no guarantee of accuracy.

“In this regard, the scientific adage ‘garbage in, garbage out’ readily springs to mind,” he wrote.

In the case of Mr Knox — a campaigner from the outset for a Royal Commission — there was “grave suspicion” that it worked against him and shortened his time in remission. Mr Knox relapsed and had a stem cell transplant.

“For much the same reasons as expressed in relation to the other affected patients, it is not possible to conclude that on the balance of probability his period of remission would have been longer,” Mr Schapel found.

He also called for a statewide electronic prescription system that was uniform across all haematology departments in SA.

TIMELINE TO A TRAGEDY

JANUARY 19, 2015: A clinician discovers that chemotherapy doses for leukaemia patients are incorrect due to a typographical error. Ten patients have received only half doses between July 2014 and January 2015.

JUNE 23: Patient Johanna Pinxteren, 76, dies.

AUGUST 1: The Advertiser reveals the underdosing bungle.

AUGUST 3: Health Minister Jack Snelling says “no one has died’’ and Professor Peter Bardy says “they’re all still with us”.

AUGUST 5: Inquiry ordered after The Advertiser reveals one patient wrongly dosed at FMC three days after the mistake was uncovered at RAH.

NOVEMBER 27: Inquiry finds significant clinical governance failures, failure to follow guidelines in using non-standard protocol, inadequate supervision, failure of certain clinical staff to report and lodge the incident, tell patients what happened, or respond clinically.

NOVEMBER 27: Andrew Knox reveals he was one of the 10 patients.

FEBRUARY 8, 2016: Eight clinicians involved in the scandal are referred to the national regulator for potential disciplinary action,

FEBRUARY 24: Legislative Council select committee established.

MAY 28: Bronte Higham tells The Advertiser he has weeks to live and is still waiting for an apology and compensation.

JUNE 1: Premier Jay Weatherill promises offers of compensation will be made.

JUNE 6: Offers of $100,000 sent to victims with the promise that legal fees will be paid.

JUNE 8: One family docked $18,000 for previous settlement, legal fees not paid.

JUNE 11: The head of SA Health, David Swan, resigns. RAH head of cancer Dr Peter Bardy has also resigned.

JUNE 30, 2016: Deputy State Coroner Anthony Schapel announces a hearing into the deaths of Mrs Pinxteren and Christopher McRea, 67, who died on November 22, 2015.

AUGUST 8: The inquest is broadened to include the death of Mr Higham, 67, who died on August 6.

SEPTEMBER 15: A report by the Australian Commission on Quality and Safety in Health Care finds that the bungle was a “disturbing and indefensible failure in clinical governance”.

DECEMBER 13: Mr Knox, 68, learns that his cancer has returned, meaning that all victims of the underdosing have either relapsed or died.

NOVEMBER 2017: Parliamentary Select Committee slams SA Health for its culture of blame, fear and inertia. Later that month clinicians start giving evidence to the Coroner’s Court about their role in the scandal.

MARCH 2019: Coroner’s report handed down