Non-inquest findings into the death of Mr B.
Deceased
Mr B
Demographics
42y, male
Date of death
2023-07-29
Finding date
2025-06-02
Cause of death
Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancreatic cancer
AI-generated summary
A 42-year-old man with metastatic pancreatic cancer died from multiple organ failure caused by iatrogenic phenol overdose during a celiac plexus block for pain management. The radiologist administered 40ml of 80% phenol instead of the intended 10% phenol concentration. Key clinical lessons include: (1) radiologists performing unfamiliar procedures must actively seek detailed knowledge from literature and colleagues, not assume medication is pre-prepared correctly; (2) hospitals must not stock high-concentration neurolytic agents without clear labelling requiring dilution; (3) procedure guidelines are essential for all staff involved in specialized interventions; (4) clinical deterioration during procedures (tachycardia rising to 160bpm) should trigger immediate escalation and code activation; (5) medication verification at point of use by multiple staff members is critical. The radiologist had not previously used phenol, relied on outdated prior case reports showing higher volumes, and failed to verify the concentration or dilute appropriately. Systemic failures included absence of written protocols, storage of concentrated phenol in unlocked cupboards, blanket approval without individual patient checks, and lack of pre-procedure consultation.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Drugs involved
Clinical conditions
Contributing factors
- Radiologist administered 40ml of 80% phenol instead of diluted 10% phenol
- Radiologist lacked training and knowledge in phenol use, having previously only used ethanol
- Radiologist did not actively seek detailed knowledge from literature or colleagues about phenol
- Radiologist assumed medication was pre-prepared at correct concentration based on previous experience
- Absence of written procedure guidelines for celiac plexus block at RBWH
- 80% phenol stored in unlocked drug cupboard without clear labelling requiring dilution
- Radiologist consulted outdated prior case reports showing 12-20ml doses (appropriate for ethanol, not 80% phenol)
- Society of Interventional Radiology guideline did not specify phenol concentration or dose
- Blanket approval by RBWH Medicines Advisory Committee for 80-90% phenol without formal submission to Queensland Health MAC
- No pre-procedure consultation performed
- Delayed recognition and escalation of patient deterioration during procedure
- Radiologist did not call medical emergency despite tachycardia rising to 160bpm and clinical deterioration
Coroner's recommendations
- RBWH to investigate provision of pre-diluted phenol product by external provider in response to clinician feedback
- DMI to identify high-risk interventional radiology procedures and implement formalised department peer support program for new medical staff and fellows
- DMI to determine maximum volume of 80% phenol required for neurolysis and Director of Pharmacy to investigate procurement of single-use volumes
- RBWH to develop regulatory framework/guideline documenting supply and administration processes for phenol neurolysis
- Elimination of 80% phenol from Queensland Health facilities with statewide Patient Safety Notice issued
- Implementation of pre-diluted 10% phenol in aqueous solution from compounding pharmacy with maximum 20ml dose per case via prescription
- Adoption of formalised peer support programme for newly commencing consultants on high-risk procedures
- Implementation of forcing function in electronic medical record requiring second person confirmation prior to procedure
- Review of Time Out check procedures to ensure medical officer/proceduralist leads the check
Full text
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