Both men received five times the recommended dose
Two Birmingham cancer patients died when they were neglectfully given too large a dose of a drug, an inquest jury has ruled.
They returned a verdict of accidental death, to which neglect contributed, on Baljit Singh Sunner and Paul Richards.
Mr Sunner, 36, of Stechford, and Mr Richards, 35, of Sutton Coldfield, died on 21 July 2007 at Heartlands Hospital.
A mix up between a doctor and nurses meant they were given five times the correct dosage of amphoterecin.
The inquest heard there were two types of the drug - one, known as fungizone, which was administered at 1mg per kg and another, known as abelcet, which was administered at 5mg per kg.
Warnings not checked
Fungizone was given in smaller doses because it entered the blood stream quickly while abelcet binds to fat and is released into the blood stream more slowly.
A doctor who had just begun working on the oncology ward had intended to prescribe abelcet but had simply written "amphoterecin" on the prescription.
The nurses thought she had prescribed fungizone and administered the wrong drug to both patients without checking the warnings on the packaging.
Both men died a few hours after being given the incorrect dose.
Outside the inquest Mr Richards' widow Lisa Richards-Everton, who is now looking after their three children alone, said: "I'm just totally devastated by what's happened.
"Things have got to change to stop this ever happening again."
Joginder Singh Dhillon, Mr Singh Sunner's brother-in-law, said: "It's too late for us but it's very important that lessons are learned."
In a statement read out by their solicitor, the families said the National Patient Safety Agency had been "slow to react" to reported incidents of the wrong form of the drug being administered in the US and Canada.
The statement added: "Serious questions must now be asked by the Department of Health, the National Patient Safety Agency and at all levels in the NHS why there was a delay in dealing with these risks."
Birmingham Coroner Aiden Cotter said he would report the case to the General Medical Council and the Nursing Medical Council "so that they can decide whether action can be taken either specifically or generally".