In January 2001, 18-year-old Wayne Jowett died whilst receiving treatment for Leukaemia at the Queens Medical Centre, in my home city, Nottingham.
The chemotherapy consisted of two drugs: Cytosine, a drug that is injected directly into the spinal fluid and Vincristine, a drug that is injected into the patient’s blood.
A tragic accident
The doctor on duty that day, Dr Feda Mulhem, made a mistake, a mix up. Instead of injecting the Vincristine into Wayne’s vein he injected it into his spine.
It was a fatal mistake. Vincristine is a potent chemical, deadly when injected into the spine. The hospital staff soon noticed their mistake. Desperately they attempted to reverse the treatment but to no avail.
Slowly Wayne became paralysed. One month later he died. It was hopeless. In the end they decided to turn his breathing machine off.
Blame the Doctor
Of course the Doctor was to blame, Wayne was under his supervision.
Dr Mulhem was tried for manslaughter and ultimately received an eight month sentence after admitting the lesser charge of unlawful killing.
Wayne’s father was deeply unhappy: “Eight months for the killing of my son is absolutely ridiculous. It leaves a sour taste in my mouth.”
A series of failures
The tragedy occurred after a series of failures in a very complicated procedure:
- Wayne Jowett arrived late at the hospital. His normal Doctor had left
- Despite asking to be called, nobody contacted his physician when Wayne arrived
- The two drugs should have been delivered to the ward on separate days. They weren’t
- Both drugs were delivered in syringes that could be fitted to the spinal needle
- Dr Mulhem had never been told about Vincristine before
- Dr Mulhem didn’t read the medical chart properly
If a single one of these failures hadn’t happened then Wayne would be alive and well. But all the errors happened in a row. Accident prevention experts call it the Swiss Cheese Effect. All the holes lined up.
Yes the doctor made a mistake.
We all make mistakes.
The real tragedy
This is not the first or last time Vincristine has been administered incorrectly
- In 1976 Lee Duggins died in exactly the same way in England
- In 1989 Ryan Bishop died in exactly the same way in Canada
- In 2004 Guido Squillaci died in exactly the same way in Australia
It has happened over 30 times.
Blame and punishment is worse than useless
It is a natural human instinct but blaming people and punishing them doesn’t help. Everybody makes mistakes, punishing them after the event won’t stop that. It is as useful as closing the stable door after the horse has bolted.
But it is worse than that, scapegoating makes errors more likely:
- Apportioning blame scares people
- And because they are scared they won’t admit they made a mistake
- And because they don’t admit to the mistake nobody knows it happened
- And because nobody knows it happened the causes of the mistake don’t get fixed
Dr Mulhem isn’t going to make the same mistake again. But somebody else will.
A bad system will always beat a good person ~ Anon
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