An internal hospital inquiry into the deaths of two Birmingham cancer patients from drug overdoses found there were numerous failings by staff and management, an inquest has heard.
Dr Clive Rayner, medical director at Heartlands Hospital, disclosed the findings into why Paul Richards, aged 35, from Sutton Coldfield, and Baljit Singh Sunner, aged 36, from Stechford, died on Ward 19 after receiving five times the normal dose of fungal infection drug Amphotericin.
He told Birmingham Coroner’s Court that there was a failure by a doctor to prescribe the appropriate dose, a failure by two nurses to spot the mistake and then make up the wrong quantity and a failure by the hospital trust to prevent this error from happening in July 2007.
The jury of seven also heard British medics were not warned on dangers of Amphotericin by the NHS’ National Patient Safety Agency after a woman died in Texas, America, when she was given a ten-fold overdose, also after confusion over dosages, the year before.
Confusion arose as the original form of Amphotericin, branded as Fungizone and referred to as “conventional”, has a dose of about one milligram per kg of a patient’s weight, but modern forms, branded as Ambizone and Abelcet, have dosages of three and five milligrams per kg.
Dr Rayner said the inquiry found junior doctor Dr Kiran Tawana was told to prescribe “conventional” Amphotericin, but as she had only prescribed it once, she resorted to an internet version of the British National Formulary medicines manual after being unable to find a paper copy.
The court heard limitations with the internet site meant she did not realise there were various forms of the drug with different doses.
She prescribed the five milligram dosage from an internet page about Abelcet but used the generic name of Amphotericin, which ward staff routinely took to mean the “conventional” form.
Nurses Vongai Gondo and Catherine Kunatsa then made up the prescriptions without realising this error.
“The doctor looked at one form of Abelcet and assumed it was the same dosage for the conventional Amphotericin,” said Dr Rayner.
“The right drug was given, but it was the wrong dose. There were more failures than just one but I feel that a doctor’s error did occur.”
Dr Tawana, who now works at Edgbaston’s Queen Elizabeth Hospital, invoked Rule 22 of the Coroner’s Rules, along with nurses Ms Gondo and Ms Kunatsa, giving them the right not to answer questions in the witness box as it may incriminate them.
The inquest is set to draw to a close with the jury deliberating its verdict on Monday.