Thursday, April 14, 2016
By Sanath Lamabadusuriya
Recently there had been articles in the "Sunday Island" and daily "Island" newspapers by Carlo Fonseka and Susirith Mendis regarding this topic. I wish to relate a personal experience.
In the late seventies when I was on sabbatical leave, I started a locum consultancy at Pilgrim Hospital, Boston, Lincolnshire. On the very first night, as the hospital lay workers were on strike, no food was available in the hospital canteen. An SHO very kindly invited me to their place for dinner. While having dinner, the SHO's bleep went off and he went to see a patient. He returned about 30 minutes later and continued with his dinner. He did not tell me what the call was about. Later around midnight, I was woken up by the SHO who wanted me to see a patient in the ward. It was an infant aged about 6 months who was having continuous seizures. This was the patient he had seen while we were having dinner. He told me that as he suspected meningitis, he had performed a lumbar puncture and given intrathecal Penicillin. When I inquired about the dose, I was shocked to hear that he had given 80,000 units intrathecally! Fortunately for him, he had not made an entry in the notes about the dose. I told him straight away that it was a neurotoxic dose and asked him not to divulge anything to anyone. The patient had continuous seizures and died in the early hours of the morning. The CSF report was normal. A pathological post mortem was performed by the hospital pathologist and the probable cause of death was given as viral meningitis/encephalitis (obviously he was not aware about the intrathecal penicillin). If I had reported the matter, there would have been an inquiry and probably the SHO would have been struck off the GMC register.