First detailed account of how the chemo bungle scandal began delivered at inquest by Deputy Coroner Anthony Schapel

THE clinical assistant who made the initial devastating error in the chemotherapy bungle told an inquest this week that she did not know why she wrote “once” daily in capital letters when the correct drug dose was twice a day.

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THE clinical assistant who made the initial devastating error in the chemotherapy bungle told an inquest this week that she did not know why she wrote “once” daily in capital letters when the correct drug dose was twice a day.

“You don’t remember where you got that from?” Che To was asked by counsel assisting, Naomi Kereru.

“No, if I remember (sic) where I got it from, I would not have done that,” she said.

The first detailed account of how the mistake happened came during the inquest by Deputy Coroner Anthony Schapel into the deaths of four of the 10 patients who were wrongly dosed and into a fifth case, of Andrew Knox, who has relapsed.

On the day in July 2014, Ms To was going on leave and wanted the RAH head of haematology, Associate Professor Ian Lewis, to sign off on a changed drug protocol before she left. She took a revised ­version, which now contained the error, to him and sat with him for 15 minutes while he checked it through.

Bronte Higham, who was one of the 10 chemo patients who were underdosed, giving evidence to the parliamentary inquiry. He has since died.

A much thinner chemo underdosing victim Andrew Knox after giving evidence in the Coroner’s inquest.

Ms To said she did not think she rushed him, even though she was about to leave on a five-day university camp where she would be thinking about “how many sausages I have to cook”.

“I don’t know whether, even though I think I’m calm, whether it actually came out, I don’t know,” she said.

Ms To, who was visibly upset, said she held herself morally responsible for the error, even though Prof Lewis signed off on it. Ms To – whose husband, Professor Luen Bik To, is a senior doctor in the same department – last year moved to a new job, which involves junior staff orientation.

Anne Pinxteren, also known as Johanna, also died.

The focus of the inquest will now shift to what happened once the mistake was discovered, which goes to the heart of the criticisms of the culture in SA Health.

It was the poor response by the RAH – including the circulation of a correction that was so low-key that Mr Knox was wrongly dosed the following week – the lack of concern for safety procedures, the failure to inform patients promptly and their appalling treatment by SA Health and its insurers that turned an error into a scandal.

“To make a mistake of this magnitude is a terrible thing, but the issues that concerned the committee even more were what can only be described as the shocking mishandling and inaction by some senior clinicians and bureaucrats that followed,” said Labor MLC Gail Gago, a member of the parliamentary select committee that coincidentally reported this week on the chemotherapy underdosing.

In the next few weeks Prof Lewis will take the stand, as will the doctor who discovered Ms To’s error and responded to it, Dr Agnes Yong.

Jack Snelling was health minister at the time The Advertiser broke the news of the chemo underdosing. Picture: Sam Wundke

On a positive note, the chair of the select committee, Liberal MLC Andrew McLachlan, told Parliament he believed SA Health and its executives understood the challenge ahead.

“(They) acknowledged the pain and suffering they had caused these patients,” he said.