Non-inquest findings into the death of Mr B.

42y · Male·Multiple organ failure due to iatrogenic phenol overdose due to metastatic pancreatic cancer

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 The radiologist had not previously used phenol, relied on outdated prior case reports showing higher volumes, and failed to verify the concentration or dilute appropriately.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.