Coroner's Finding: MCRAE Christopher, PINXTEREN Johanna, HIGHAM Bronte, BAIRNSFATHER Carol
Demographics
unknown
Finding date
2018-06-01
Cause of death
acute myeloid leukaemia
AI-generated summary
Four patients with acute myeloid leukaemia died after receiving chemotherapy consolidation therapy that was administered once daily instead of the intended twice daily schedule due to a protocol error. The error originated at Royal Adelaide Hospital and was replicated at Flinders Medical Centre. While the anatomical cause of death was AML in all cases, the coroner found jurisdiction to investigate whether the chemotherapy underdosing contributed to or hastened the deaths. The key clinical lessons include the importance of robust clinical governance procedures for protocol accuracy, timely error detection and communication across facilities, and appropriate adverse incident reporting systems. Medical teams must ensure chemotherapy protocols are correctly transcribed and communicated, with verification mechanisms in place. The case highlights how systemic failures in protocol management and inter-hospital communication can lead to patient harm.
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 - once daily instead of twice daily administration
- poor clinical governance at Royal Adelaide Hospital
- protocol error replication at Flinders Medical Centre
- inadequate adverse incident reporting and communication
- failure to immediately amend erroneous protocol at Flinders Medical Centre after error detected at Royal Adelaide Hospital
- lack of specific clarification in email communication about protocol correction to haematology clinicians
Coroner's recommendations
- Implement robust clinical governance procedures for chemotherapy protocol accuracy and verification
- Establish timely and clear communication protocols for adverse incident reporting across hospital facilities
- Ensure chemotherapy protocols are correctly transcribed, verified and communicated with explicit dosing frequencies
- Implement mechanisms to promptly detect protocol errors through prescription review processes
- Establish procedures to immediately amend and communicate detected protocol errors across all affected facilities
- Ensure adverse incident notifications include specific identification of errors and changes required, not merely new requirements
- Review and strengthen inter-hospital communication and protocol harmonisation processes in public health systems
Full text
Related cases
Source and disclaimer
This page reproduces or summarises information from publicly available findings published by Australian coroners' courts. Coronial is an independent educational resource and is not affiliated with, endorsed by, or acting on behalf of any coronial court or government body.
Content may be incomplete, reformatted, or summarised. All court orders for redaction and non-publication are respected; documents with technically defective redaction have been excluded from the database entirely. Always refer to the original court publication for the authoritative record.
Copyright in original materials remains with the relevant government jurisdiction. AI-generated summaries and tagging are for educational purposes only, may contain inaccuracies, and must not be treated as legal documents. We welcome feedback for correction —