Incorrect method of drug administration led to deaths – findings

Deaths of 3 children at GPHC

The doctors who treated the three juvenile leukaemia patients who later died at the Georgetown Public Hospital Corporation (GPHC) administered the drugs incorrectly. Instead of intrathecal administration of the drug vincristine, they administered it intravenously. It was this that led to the adverse reactions of those three children and ultimately their deaths.
This is according to Deputy Chief Medical Officer (CMO), Dr Karen Gordon-Campbell, who on Friday at the GPHC’s press briefing, stated that investigations revealed that protocols the medical practitioners should have followed would have stipulated which drug has to be administered “when and where.”

“It wasn’t a question of dosage but administration in terms of where it was administered. That was done incorrectly. The dosages would have been fine but in terms of where they administered what,” the Deputy CMO explained.
She stated that the three medical personnel involved in the matters were aware that they had broken protocol but not at the initial stage of administering the medicinal drugs to those patients.

“The reasons that were given encompassed the fact that they were stretched and maybe not fully attentive at the time. That pretty much is the long and short of the reasons given but I don’t think that initially, they realised. But eventually, when they recognised that the patients were deteriorating when they checked they realised their mistake.”

Deficiencies
Meanwhile, Chairperson of the Board of Directors at the GPHC, Kesaundra Alves told the media that an internal investigation by the hospital’s administration into the circumstances surrounding the treatment of three leukaemia patients and their subsequent adverse reactions has revealed that human deficiencies and systemic challenges contributed to the demise of those three children.

“Statements were solicited from the parties directly or indirectly involved and parties who were witnesses or otherwise privy to pertinent information that could assist with the investigation. The Director of Medical and Professional Services, Dr Jeffery, submitted his final report to the Chief Executive Officer on January 28, 2019. That report concluded that human deficiencies and systemic challenges contributed to the demise of the three children.”
She stated that an independent investigation by the Public Health Ministry was also launched and findings were similar to those of the GPHC’s; non-adherence to the hospital’s protocols led to the three young children succumbing at the GPHC.
Alves explained that the GPHC Board only received the Ministry’s report quite recently and is still reviewing both reports in its possession.
“As part of its remit, this Committee (from the Public Health investigation) conducted a fact-finding condition. Through the review of each patient’s chart, interviews with the relevant staff members of the GPHC and also with the parents of the patients. The Committee’s preliminary report was submitted on February 22 and its final report was submitted to CMO to February 28, 2019.”
This final report has also recommended a number of measures to strengthen the GPHC’s system and prevent a recurrence.
According to the Board’s Chairperson, throughout both investigations, officials of the Ministry, Board of Directors, and the administration of the GPHC interacted with the relatives of the three children and officially informed them on Friday of the findings of the investigations.
The GPHC will shortly commence the process of initiating action following the findings of these two reports, she noted.
However, the GPHC is not the body that will determine the final outcome of those staff that were being investigated.

Administrative leave
“That matter is not within our hands. Contractually we can determine who works at GPHC but who is licenced to practice medicine in Guyana is a matter for the Medical Council of Guyana to handle. So we went as far as we could, sending them on admin leave pending a review of reports by the Board of Directors of the GPHC. As I said, this report came into our possession this week and the Board hasn’t, the Chairman has not had the chance to review it.”

According to the GPHC’s Board, the Guyana Medical Council has already requested information from the entire findings of these investigative proceedings.
Meanwhile, CEO of the GPHC, Brigadier George Lewis stated that with regard to the three medical staff involved in the incidents, their administrative leave commenced on January 29, 2019, and they remain on administrative leave pending further review of the report and possible disciplinary actions if necessary.

Compensation
In terms of compensating the affected families, no decision has been made as yet by the GPHC since the reports still have to be reviewed, Lewis explained.
“There are a number of processes. At this stage we are reporting to you the findings of the investigation, the next stage would involve the hospital administration engaging the Board of Directors which will have the opportunity to study the reports and thereafter…all options are on the table. We can decide on that but in terms of me saying to you today that compensation will be offered I don’t have that type of answer.”
The first child who died was 7-year-old Curwayne Edwards on January 14, followed by three-year-old Roshini Seegobin of Enmore, East Coast Demerara (ECD) on January 18.
The third child, six-year-old Sharezer Mendonca of Queenstown, Essequibo Coast, died on January 24. Mendonca’s body was given to the wrong family for burial in what was alleged to have been an attempt to cover up her true cause of death. (Kristen Macklingam)