New rules to save patients' lives

Doctors wrongly injected Vincristine into Wayne Jowett's spine

Independent investigators have called for changes to prevent any more drug blunder deaths like that of Wayne Jowett.

Wayne, aged 18, died in February, after the leukaemia treatment Vincristine was wrongly injected into his spine rather than a vein.

Since 1975 there have been at least 13 similar incidents in Britain - almost all of them proved fatal.

Medical investigators looking into the tragic deaths have called for design changes to make sure the drugs can never again be confused.

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Investigators looking into the death of teenager Wayne Jowett have highlighted the drug packaging and syringe design faults that contributed to his death.

Wayne was in remission after suffering from acute lymphoblastic leukaemia, but he still needed three-monthly injections of two chemotherapy drugs - Vincristine and Cytosine.

Professor Toft's investigation has highlighted classic systems failure as the cause of Wayne's death - human error coming at the end of a long chain of events where fail-safes and procedures did not prevent the fatal error occurring

CMO Professor Liam Donaldson

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.

But both drugs can look very similar and this can have fatal consequences.

Both are in similar sized syringes and both are clear liquids.

Chief Medical Officer (CMO) Professor Liam Donaldson has pledged to reduce the number of deaths from wrongly-administered spinal injections to zero by next year.

He commissioned two reports into the problems of spinal medication errors.

The first by Professor Kent Woods, director of the NHS Health Technology Assessment Programme, has called for changes in equipment to make it possible to inject drugs such as Vincristine into the spine.

To achieve this Vincristine should only be made available in an infusion bag to be attached to a drip. The drug should also be colour-coded.

Dedicated team

Professor Woods also recommended that chemotherapy treatments are only given by a dedicated and specially trained team.

He said the two drugs should never be made available on a ward at the same time, should never be administered at the same time, and should never be administered by the same person.

He wanted to see a clear national policy on the handling of chemotherapy drugs so that doctors moving from one hospital to another always know the correct procedures.

A second report by Professor Brian Toft, a non-medical consultant who assusted in the inquiry into the Ladbroke Grove train crash, looked into the circumstances surrounding Wayne's death.

This identified classic "systems failure" as the cause of death.

The report highlighted the problems found in Nottingham and called for changes in procedures at the hospital, protocols and training measures for doctors.

Professor Donaldson said: "The death of Wayne Jowett was a terrible tragedy.

"Professor Toft's investigation has highlighted classic systems failure as the cause of Wayne's death - human error coming at the end of a long chain of events where fail-safes and procedures did not prevent the fatal error occurring."