A Trial on Error

Safety-First-Patient-safety-allianceRichie Williams was young boy of 12. He was suffering from leukemia (blood cancer) and was undergoing treatment at the Great Ormand Street Children’s Hospital which specialised in treating such patients. Richie used to receive anti-cancer medicines in a cyclical manner. He used to go to the hospital on a pre-scheduled day to receive his dose of chemotherapy. They used to give him a dose of injection Vincristine by intravenous route. Another dose of injection methotrexate would be injected intra-thecally (injection between the spaces in the back bone, typically called as spinal injection). Being young, Richie used to get a small dose of sedative first and then the spinal injection would be given to him. He was doing well and recovering fast. In fact, he was almost at the end of the chemotherapy regime.

In the month of July 1997, Richie as usual went to the hospital. He was always instructed to come ‘Nil by mouth’ (empty stomach) to the hospital. On that day in the morning someone offered him a cookie. The young boy simply could not resist it and quickly ate it. Richie got admitted as usual to the chemotherapy ward. Dr. Murphy was on his morning rounds and saw Richie in the ward. Dr. Murphy was a senior doctor working at the hematology department of the Great Armond Street Children’s Hospital. “Hi Richie! How are you doing today?” he asked Richie.

“Thanks, Doc. I am fine. But I want to make one confession. I have eaten a cookie just on my way,” Richie said. Now Dr. Murphy was in a fix. Riche’s appointment was scheduled for long. Since Richie was not ‘Nil By mouth’, it was risky to give me the sedative. Since sedative could not be given, the spinal injection and the dose could not be given. There was no point in rescheduling the appointment as Richie’s school examination was approaching. Too much of delay would surely have been detrimental to Richie’s recovery. Richie’s parents were co-operative. They understood the problem. It was decided that Richie should be brought in at 4 pm on the same day. This elective procedure could be done ‘in emergency hours’ after 4 pm.

The blunder

Richie came in at 4 pm as decided. He had to be admitted in another ward as the hematology ward was not vacant. In emergency hours, Richie was sent to the operation theater for the spinal injection. By that time, Dr. Murphy was off duty. Dr. Lee was on the duty. Dr. Lee was known to be a studious doctor and was very popular amongst his patients for his empathetic reassuring approach. He was senior to Dr. Murphy and was an expert in paediatric anesthesiology. He had given many such injections in the past. Dr. Lee phoned Dr. Murphy who was off duty to check whether there was anything specific he had to take care of, while doing the job. Dr. Murphy said, “Well, it is a straight forward spinal injection and that’s it”. This was completely true!

Dr. Lee started the procedure. He carefully cross checked the consent and the identity of the patient. He swiftly gave a small dose of medicine to put Richie to sleep. Vigilantly, he changed Richie’s body position and made him lie on the side. He confirmed that the oxygen saturation of the Riche’s blood was well maintained and started applying the antiseptic solution to the back to prepare the part for the spinal injection. He had already told the senior staff nurse to check the expiry date on the injection. The nurse also confirmed that the injection was meant for the same patient Richie Williams. The doctor’s needle swiftly entered the space where it had to be in the first shot. The nurse handed over the syringe to Dr. Lee who attached it to the needle and off went the medicine in the spinal space. He carefully changed the patient’s position. As soon as this was done, the nurse came running frantically. She said, “Dr. Lee, I found one more injection in the name of the patient Richie”. And Dr. Lee was dumb stuck. “One more injection?” he cried loud. Dr. Lee confirmed it. It was true. The injection read “Injection Methotrexate. Richie Williams”. Dr. Lee realised what had happened. The injection which should have been given by intravenous route (via the vein in the hand) had been given in the spine.

Dr. Lee was shattered when he realised what the blunder was. The staff started running helter-skelter under tremendous stress. Senior doctors were contacted. The outcome was clear… the spinal cord almost dissolves when vincristine in that dose is given in to the spine. Richie’s death was inevitable now. The doctors tried everything that was possible to save him. Dr. Lee was sitting next to Richie personally monitoring the condition. Richie died. The medicine that was supposed to cure him of the cancer had killed him!

The police arrested Dr. Lee and Dr. Murphy under the charges of manslaughter. The media and news channels started bombarding the news. Some called the doctors criminals, murderers, monsters who should be hanged to death. Those doctors and patients who knew Dr. Lee were talking about him. Some still said that he had a great track record. Some held him negligent and responsible for the death. Some said that it was a sad and unfortunate event. Some senior doctors criticised “the juniors” for impatience and gave examples of their “days” and “how they used to work in the past”.

The Trial that followed

The trial started in the court. Professor Alan Aitkenhead, Head of the Department of Anesthesiology from Nottingham University was appointed as an expert. He made elaborate inquiry in the incidence. The incidence had its roots into multiple small incidences, facts and errors. It all started from the fact that Richie had eaten the biscuit due to which the case had to be postponed. He was admitted at 4 pm in another ward as there was no vacancy in the hematology ward. It was the policy of the hospital to first give the vincristine injection in the ward itself, so that only one injection would reach the operation theater. On that day, the nurse in charge of the general ward where Richie was admitted was not aware of this policy. She sent both injections to the operation theater. The staff in the operation theater and Dr. Lee could have not have even imagined that such a thing would have happened. It was true that if he would have carefully gone through all the case papers he could have understood it. But he believed his colleagues and assistants with whom he worked all these years. It was found that the same mistake or error had happened across the world on 15 different occasions in different hospitals so far.

The court ultimately decided the matter. The court considered that the crime of manslaughter could not be made out. The court concluded that the death was a result of series of mishaps and failings in the hospital systems rather than gross negligence. The error on the part of Dr. Lee was in the end of the chain of multiple lapses. The court absolved Dr. Lee from the charges of criminal negligence and the civil case continued further. The hospital had already removed Dr. Lee from the job. At a later date, the hospital struck out of court settlement by paying exemplary compensation to the parents.

Dr. Lee’s dreams were totally shattered. He could not come out from the trauma. He could not imagine that he was instrumental in killing one of his patients. Ultimately he left the United Kingdom. Few years later, he committed suicide.

The incidence had claimed not one but two lives! The WHO is now looking at healthcare professionals involved in such incidences as “Second victims of patient safety accidents”.

Friends! What do you think after reading this true story? Whose mistake was it? Was it a human error? Or defective system? Or just an outcome of an unlucky day? Tell me your comments and thoughts.

Write to me at: drnikhil70@hotmail.com



One thought on “A Trial on Error

  1. kino winterthur

    I am not sure where you are getting your info, but great topic. I needs to spend some time learning more or understanding more. Thanks for wonderful information I was looking for this info for my mission.

Comments are closed.