Cancer patient died after hospital error

HUMAN error and defects in hospital procedures led to a cancer patient being given a lethal dose of the wrong chemotherapy drug, it was ruled yesterday.

Alexander Cusker, 75, died after pharmacy staff at Gartnavel General Hospital in Glasgow mistakenly gave him a dose of Chlormethine in June 2005.

After a fatal accident inquiry, Sheriff James Mitchell found that mistakes on the part of two employees at the hospital's aseptic dispensing unit and defects in its standard procedures had led to Mr Cusker being given the drug.

The inquiry at Glasgow Sheriff Court heard that a pharmacy technician had selected Chlormethine for the pensioner instead of Carmustine, which he had been prescribed.

The mistake was not detected by an experienced pharmacist and the medication was released.

The married father of three from Cambuslang, who had been diagnosed with mantle cell non-Hodgkin's lymphoma, became unwell within days.

After receiving the wrong drug, his health deteriorated with "distressing and unpleasant consequences", and he died at Gartnavel about two months later.

In his published determination, Sheriff Mitchell said it was not in dispute that the administration of the wrong drug had led to Mr Cusker's "untimely death".

He added: "The undisputed evidence led at this inquiry has highlighted defects in the standard operating procedure, which did not prevent the release from the unit of not only the wrong chemotherapeutic drug for Mr Cusker but also did not prevent him receiving about five times the appropriate dosage of that wrong drug."

During the inquiry, the court heard that, had Mr Cusker continued on his prescribed course of chemotherapy, he may have lived for up to a further two years.

The sheriff noted that checks and system changes had been introduced at the hospital since the mistake happened.

He added that the selection of the wrong drug by the pharmacy technician had been a "serious but human error".

The sheriff expressed his condolences to Mr Cusker's family.

He said Mr Cusker's son had expressed the view that there had been "systematic failures" which resulted in his father's death.

"I sincerely hope that this inquiry has served to give him and his family a clear picture as to how it came to be that a dearly loved husband and father received an overdose of the wrong chemotherapeutic drug," the sheriff added.

A spokeswoman for NHS Greater Glasgow and Clyde said: "Our thoughts are with Mr Cusker's family at this difficult time.

"We fully accept the sheriff's determination and have already taken steps to review and revise our policies and protocols.

"A range of actions have been taken in response to our own internal investigation into the circumstances of this case."