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Too much of the wrong chemotherapy drug that killed an elderly cancer patient was the fault of human error and defects in hospital procedures, a sheriff in Scotland has ruled.
Alexander Cusker, 75, died after pharmacy staff at Gartnavel General Hospital in Glasgow mistakenly gave him a dose of chlormethine – related to mustard gas – instead of carmustine.
Sheriff James Mitchell found that errors on the part of two employees at the hospital’s dispensing unit and defects in its procedures were to blame.
The health of Mr Cusker, who had mantle cell non-Hodgkin’s lymphoma, had deteriorated with “distressing and unpleasant consequences”, and he died two months later.
In his published determination, Sheriff Mitchell said it was not in dispute that the administration of the wrong drug had led to Mr Cusker’s untimely death.
He added: “The undisputed evidence has highlighted defects in the standard operating procedure, which did not prevent the release from the unit of not only the wrong chemotherapeutic drug but also did not prevent him receiving about five times the appropriate dosage of that wrong drug.”
A spokeswoman for NHS Greater Glasgow and Clyde said: “We fully accept the sheriff’s determination, and have already taken steps to review and revise our policies and protocols.”
Copyright Press Association 2008