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Thursday, April 14, 2016

Medical Negligence

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.


4 comments:

  1. Sanath
    Thank you for your story which raises many questions ethical, moral and professional. It is far easier to be wise after the event, this time after the passage of many decades.
    Over the years I have known you as a man of principles and appreciate the honesty with which you have related this unfortunate incident. I have no doubt in my mind you did your best in the circumstance all those years ago.

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  2. A very interesting ethical dilemma. If the matter came into the open, the poor SHO would have been in deep trouble. On the other hand he was probably guilty of taking the life of an innocent child, albeit a result of a mistake and not in any way intentional. If this happened these days, he wouldn't have escaped as the dose and drug would have been written down and checked by another person (and it is also likely that a competent nurse who did the check would have brought to his notice that the dose was wrong and the mistake may have never happened). The other possibility is that a nurse may have known that the wrong dose was given and the danger of that person making an accusation of a 'cover-up'.

    He must have been very distressed by what happened and that itself would have been a "punishment" he had to endure and your action saved this young person's career. If this is posed as a question, I am sure opinion would be divided as to what the correct action should have been. Thanks for your honest contribution Lama.

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  3. This sounds like a doctor's worst nightmare. No doubt some of us have been involved to some extent in such events in a lifetime of practice and look back with 'If only' feelings. The moral for any professional involved in the care of patients is never stop to double check, never fail to get advice from a superior, never fail to check up in the formulary, never feel it's beneath your dignity to think and say, I don't know all that is to know, so let me ask for advice and finally never feel hesitant to phone your next higher in command, thinking 'it's late, it's raining, it's cold, or he/she may think I am incompetent. We are entrusted the highest responsibility in life, let's take no chances at all. I hope medical students and young doctors read Sanath's account.
    Zita

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  4. This would have been a very disturbing and distressful event for all parties concerned -not in the least the family who lost their precious child.
    Mahen has laid out the other possible scenarios, and as he says this situation might have been totally different for all concerned with current practices.
    Zita has given essential good advice to all medical practitioners, to which I might add one other, that I have been trained to follow as a habit-(credit to my early consultants)-that of checking for contraindications and drug interactions prior to prescribing any medication, however familiar.
    A simple example is- a very frequently used antibiotic such as erythromycin which can cause a fatal arrhythmia in the presence of cardiac disease prone to arrhythmias or prolong the QT interval, or in combination with a multiplicity of other commonly prescribed medications such as antihistamines, antifungals etc.
    I have found this a very worthwhile habit in my day to day practice.

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