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Thursday, 19 April, 2001, 16:06 GMT 17:06 UK
Catalogue of blunders that led to death
Vincristine packaging
The stark warnings are clear on Vincristine packaging
Investigators have revealed that a catalogue of blunders led to the death of teenager Wayne Jowett.

Wayne, aged 18, died in February at the Queen's Medical Centre, Nottingham, after a cancer drug was wrongly injected into his spine rather than a vein.

An independent report has criticised staff and procedures at the hospital another report has highlighted design faults in syringes and drug packaging.

One investigator said the "entire" staff on the day ward where Wayne was treated had been "lulled into a false sense of security" and had forgotten that mistakes could be made.

Wayne Jowett was diagnosed with acute lymphoblastic leukaemia in 1999.

By June last year he was in remission, but still needed three-monthly injections of two chemotherapy drugs - Vincristine and Cytosine.

The Cytosine is injected into the spine whereas the Vincristine is administered intravenously - because it is so toxic the Vincristine is usually fatal if put into the spine.

Drug policy

Because hospital bosses were aware of the problems associated with the two drugs they had a policy of not giving patients both drugs on the same day.

But on January 4, when Wayne Jowett came to the day ward with his grandmother for his chemotherapy treatment, the two drugs had been sent from the pharmacy to the ward together.

They were in similar syringes and both clear liquids and although clearly labelled they were stored together on the ward's fridge.

But they did both have different dates for administration marked on them.

Wayne arrived late for his morning appointment, he had been very worried about the treatment and needed some time to psyche himself up.

Wayne Jowett
Wayne Jowett died after a series of blunders

The consultant in charge of Wayne's case was aware that his patient was very late, but asked ward staff to tell him when Wayne arrived.

His remarks, although heard, were not directed at anyone in particular.

And when Wayne arrived on the ward a junior doctor Dr David Morton, who had only been on the ward for five weeks, took responsibility for the case.

He had to get a specialist registrar to oversee his lumbar puncture and the administration of the drug and asked Dr Feda Mulhem to assist.

But Dr Mulhem himself had only been on the ward for two days and this was his very first job as a registrar.

Dr Mulhem was supposed to only be shadowing another doctor, not performing or supervising procedures himself.

But despite this he agreed to assist.

Emergency surgery

Neither of the two doctors had any formal training in giving chemotherapy drugs and both wrongly assumed that the other had checked the drugs and knew the way they were supposed to be administered correctly.

A nurse handed the bag containing both drugs to the doctors and Dr Morton correctly injected the Cytosine into Wayne's spine.

Dr Mulhem read out the name and dose of the drug, but he did not say how it should be administered and said that when he saw the Vincristine that he was thinking of another drug which is administered spinally.

Dr Morton asked whether the Vincristine should be given spinally and said Dr Mulhem had told him yes.

He said he was surprised by this, but had not felt he could challenge a superior.

Dr Mulhem told investigators that at his previous hospital in Leicester it had been impossible to mix the drugs up and so had not thought this could possibly happen at Nottingham.

Within minutes the mistake was realised and desperate efforts were made to reverse the procedures, but despite the emergency surgery it was too late.

Wayne's body became slowly paralysed, his breathing started to fail and almost a month later his parents agreed to turn off his life support machine.

Both doctors involved in the case have been suspended pending the outcome of the investigations.

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See also:

19 Apr 01 | Health
'Wayne was in a lot of pain'
19 Apr 01 | Health
Drug blunder death 'accidental'
19 Apr 01 | Health
New rules to save patients' lives
02 Feb 01 | Health
Drug blunder patient dies
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