Coroner's Finding: MCRAE Christopher, PINXTEREN Johanna, HIGHAM Bronte, BAIRNSFATHER Carol - Ruling
Deceased
Johanna Pinxteren, Christopher McRae, Bronte Ormond Higham, Carol Anne Bairnsfather
Demographics
unknown
Date of death
2015
Finding date
2018-06-01
Cause of death
Acute myeloid leukaemia (AML)
AI-generated summary
Four patients with acute myeloid leukaemia (AML) died following administration of chemotherapy consolidation therapy that was delivered according to a protocol containing a critical error—specifying once-daily instead of twice-daily dosing. The same erroneous protocol was used at two hospitals, causing underdosing in ten patients total, four of whom died. The protocol error originated in the haematology department at Royal Adelaide Hospital and was replicated at Flinders Medical Centre. While the anatomical cause of death was AML in all cases, the coroner held an inquest to examine whether the underdosing contributed to death or hastened mortality. Key failures included inadequate error detection procedures, poor communication between hospitals when the error was discovered on 16 January 2015, and a patient (Andrew Knox) receiving incorrect dosing even after the error was identified. The court has jurisdiction to conduct the inquest on the basis that cause of death includes unknown elements relating to the protocol error's contribution.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Specialties
Error types
Drugs involved
Clinical conditions
Contributing factors
- chemotherapy protocol error containing word 'once' instead of 'twice' for consolidation therapy dosing
- delivery of consolidation chemotherapy at once-daily frequency instead of intended twice-daily frequency
- poor clinical governance at Royal Adelaide Hospital in protocol development and management
- inadequate error detection and reporting procedures across South Australian public health system
- failure to immediately amend the erroneous protocol at Flinders Medical Centre following discovery at RAH
- inadequate communication of protocol error to Flinders Medical Centre clinicians on 20 January 2015
- email notification of protocol change did not explicitly state that change was due to identification of an error
- erroneous protocol continued in use at Flinders Medical Centre after being identified as incorrect
- patient Andrew Knox received incorrect dosing even after error discovery (22–26 January 2015)
- delay in identification of error at Flinders Medical Centre
Coroner's recommendations
- Implementation of improved clinical governance mechanisms at both Royal Adelaide Hospital and Flinders Medical Centre to prevent similar protocol errors
- Establishment of adequate procedures for reporting of adverse incidents and errors across the South Australian public health system
- Improvements to communication protocols to ensure timely and explicit notification of identified errors to all affected clinical areas
- Enhanced verification procedures to ensure protocols are correctly transcribed and implemented at all locations
- Implementation of systematic checks for consistency of protocols across hospitals using the same treatment regimens
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