Fail-safe systems to rule out the chances of fatal errors in spinal injections are expected to be introduced throughout the NHS after a coroner's verdict of accidental death last week on an 18 year old patient with leukaemia.
Wayne Jowett, an apprentice mechanic, died last February at Queen's Medical Centre, Nottingham, after the cytotoxic drug vincristine, intended for intravenous injection, was instead injected into his spine.
The coroner, Nigel Chapman, was told that 14 patients had died or been left paralysed as a result of similar errors in the past 15 years. He asked why, when scientists could put men on the moon, ways could not be found to prevent such deaths.
Dr Chapman said that Mr Jowett had been let down by medical, nursing, and pharmacy staff; the hospital had let down medical teams by not training them properly; and there were “also questions for the drug industry and the Department of Health.”
The government promised to act on three reports into the error, published last week to coincide with the inquest verdict. The chief medical officer, Liam Donaldson, commissioned one report on Mr Jowett's case by an accident investigator, Brian Toft, and another on intrathecal injection errors by Kent Woods of Leicester University's department of medicine. Queen's Medical Centre also published the findings of its internal investigation into the incident.
The injection was performed by David Morton, a senior house officer who had been on the ward for five weeks and was supervised by Feda Mulhem, who had been a specialist registrar for only three days.
Vincristine was brought to the ward at the same time as the intrathecal drug cytosine, contrary to the medical centre's policy. Dr Morton had given spinal drugs only once before.
Professor Toft identified 48 separate factors as contributing to the tragedy. He said that it was dangerous that syringes containing vincristine could also be connected to the spinal needles that delivered intrathecal drugs to patients. He recommended equipment changes to make it impossible to inject intravenous drugs into the spine, and formal training for doctors on giving cytotoxic drugs.
Professor Woods, director of the NHS's health technology assessment programme, said that only a handful of highly trained staff should be allowed to give spinal injections. Intrathecal and intravenous cytotoxic drugs should be given at different times, by different people, and in different clinical locations. He called for urgent consideration to be given to dispensing vincristine and other similar drugs either in an infusion bag or via a syringe that allows intravenous administration only.
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PRESS ASSOCIATION
Wayne Jowett: 48 separate factors contributed to his death