Inquest into deaths of four chemo underdosing patients told haematologist responsible did nothing to follow up on error

THE Coroner’s Court has heard that senior doctors failed to raise the alarm or inform patients after the chemo dose error was discovered.

RAH haematologist Professor Ian Lewis arrives at the Coroner's Court.

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THE RAH haematologist responsible for the chemotherapy mistake, Dr Ian Lewis, froze “like a kangaroo in the headlights” and did nothing to follow up the serious error that halved the doses given to seriously ill leukaemia patients.

The coroner’s court inquiring into the deaths of four of the patients on Friday heard evidence of dysfunction within SA Health, with the doctor who discovered the error, Dr Agnes Yong, waiting for Dr Lewis to act — while Dr Lewis panicked and did nothing.

The Advertiser understands that Dr Lewis and Dr Yong were stood down in May, on full pay, after the regulatory body, AHPRA, reported on their conduct.

“Like a kangaroo caught in the headlights I froze, I just did not know what to do,” Dr Lewis told the coroner’s court on Friday.

Dr Agnes Yong arrives at the Coroners Court.

After returning from holiday and being told of the error by a pharmacist, Dr Lewis later saw his senior managers, Professor Bik To, the RAH deputy director of haematology, and Professor Peter Bardy who was head of cancer services but did not mention the error. ‘‘It just didn’t come up in conversation,” Dr Lewis told the court when questioned by Mark Griffin QC.

“I have acknowledged I should have raised it with them. I cannot provide any explanation for why I did not. I froze and I am ashamed and embarrassed by that.”

Dr Yong, whose clinical knowledge led to the mistake being uncovered, told the court this week she had been waiting for her seniors to initiate a response. “I was not in the fashion of telling my bosses what do to,” she said in her evidence. But having discovered the mistake midway during the treatment of a patient, Dr Yong then increased the dose to the correct level and misled the patient, Mrs R, as to why she was getting more.

Dr Yong told Mrs R she did not get the higher dose first time around to make sure she was not given too much but as she had tolerated it well, it would be given twice a day.

“So you lied to her,” Mr Griffin said. “I did not tell the whole truth, I would not say I lied to her,” Dr Yong said. “I did not tell her the whole truth.” Dr Yong said she was not trained in disclosure and did not know what to say.

Dr Lewis apologised for the error in front of some of the patients or their surviving family members — three of whom were in tears — saying the mistake had significant implications for a large number of people. “To have received less than the intended dose is truly devastating,” he said. “I realise this will have effects on your lives for a long period of time. I cannot imagine how you must feel.”

The coroner’s inquest into the deaths of four of the 10 underdosed patients continues.