Issue: Inadvertent intrathecal injection of Vincristine in a 28 year old burkitts lymphoma cancer patient, admitted for routine chemotherapy treatment. The injection was to be administered intra-muscularly. The inadvertent intrathecal injection caused the death of the patient.

The drug was toxic and known to be fatal if injected into the spine and, despite emergency surgery to drain his cerebro-spinal fluid that was performed 4 days after when the error was discovered, the patient died a slow and painful death involving gradual paralysis from his feet upwards, resulting in quadriplegia and blindness and difficulty breathing before he eventually died, all of which was witnessed by his family who kept a bedside vigil.

Action: McLaughlin & Riordan acted for the patient and his Family in this matter on a pro-bono basis. The patient did not have any dependants and his Family did not wish to bring civil claims for nervous shock. They sought legal advice and support shortly after the inadvertent “lethal injection” was diagnosed, when their request for emergency provision of a copy of the Hospital records was responded to by Hospital administrative staff stating that they were obliged to comply with the request within 28 days and not immediately.

Outcome: This incident occurred in 2003 and well prior to the introduction of the NSW Health Directive regarding “Open Disclosure”. The Family were upset at the perception that once the mistake was realised, the hospital went into damage control mode, denying that the Family had raised concerns over the patient’s rapid decline on the day of the injection and blocking access to Hospital management.

Ultimately, the Family campaigned for the introduction of a number of changed procedures in the Hospital and across all Hospitals in Australia, based on UK 2001 protocols introduced after a series of similar errors. 

This incident resulted in significant adverse publicity for the Hospital, including local and Sydney print media; and a story on the ABC’s “7.30 Report”. The Family’s resort to the media was mainly due to its perception of the Hospital’s poor management of the catastrophe which added to the Family’s grief and need for validation.

We are of the view that, had the Hospital communicated openly with the Family akin to the “Open Disclosure” requirements, legal representation and media involvement as sought by the Family, would probably not have occurred.