Non-inquest findings into the death of Mr B.

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• Radiologist consulted outdated prior case reports showing 12-20ml doses (appropriate for ethanol, not 80% phenol)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

1. RBWH to investigate provision of pre-diluted phenol product by external provider in response to clinician feedback
2. DMI to identify high-risk interventional radiology procedures and implement formalised department peer support program for new medical staff and fellows
3. DMI to determine maximum volume of 80% phenol required for neurolysis and Director of Pharmacy to investigate procurement of single-use volumes
4. RBWH to develop regulatory framework/guideline documenting supply and administration processes for phenol neurolysis
5. Elimination of 80% phenol from Queensland Health facilities with statewide Patient Safety Notice issued
6. Implementation of pre-diluted 10% phenol in aqueous solution from compounding pharmacy with maximum 20ml dose per case via prescription
7. Adoption of formalised peer support programme for newly commencing consultants on high-risk procedures
8. Implementation of forcing function in electronic medical record requiring second person confirmation prior to procedure
9. Review of Time Out check procedures to ensure medical officer/proceduralist leads the check