Understaffing a critical component to incorrect administering of drugs

Deaths of 3 children at GPHC

The medical practitioners who incorrectly administered injections to the three leukaemia juvenile patients leading to their deaths at the Georgetown Public Hospital Corporation (GPHC) in January, treated those patients without the supervision of a senior doctor at some point during treatments.
This is according to the Deputy Chief Medical Officer (DCMO) of Guyana, Dr Karen Gordon-Campbell, who recently told the media that the scenario put together from the investigations revealed that the lack of staffing at the hospital resulted in their actions.
“The few persons that were available [were] stretching themselves between clinic, Accident and Emergency, ward rounds. Administration of the chemotherapy lead to the administration of the chemotherapy being done without the senior person being present at all times. And that I think, was part of the problem, lack of staff at the time.”
Dr Gordon-Campbell explained that in understanding that persons were being pulled “here, there and everywhere,” the three medical practitioners in question, wrote their treatment without checking on the standard operating procedures.
“A doctor administered it…but not the senior doctor. Ideally, you’d want to have a senior person at least in the room observing, ideally, or at least assure that the person that was administering was doing what they should do,” she said.
Meanwhile, GPHC’s Director of Medical and Professional Services, Dr Fawcett Jeffrey, stated when any doctor is about to treat a patient there are protocols in place that need to and must be followed.
“There are roadmaps that you need to follow when you are going to administer any form of medical attention to a patient. What happened that these roadmaps and protocols were not followed exactly as they should be. That is the reason why we ended up [with] the complications.”

Lessons learnt
Dr Jeffrey noted that while it is unfortunate that there had to be incidents such as these where the three children lost their lives, the GPHC has learnt that supervision of junior staff is critical in all departments.

“It is very important for our staff to be better supervised, juniors by seniors, and that they stick to standard protocols for the management of all pathology within the institution. Not only the management or the use of chemotherapeutic drugs, but any protocol, even if you are going to do a surgical procedure, if you are going to do any form of management, protocols are there and they are there to be followed. It was unfortunate in this case; the protocols were not followed.”

Lawsuit
The family of Sharezer Mendonca, 6, who is one of three children that died after receiving pre-chemotherapy treatment at the hospital in January, plans to sue the institution for wrongful death.
Guyana Times spoke with the aunt of Sharezer, Sherry Ann Mendonca, on Sunday who related that they are going ahead to file legal action since they are of the view that her untimely death could have been avoided had the doctors and nurses paid careful attention to what they were doing.
Mendonca said that her family plans to push for the licences of those directly involved in her niece’s death to be revoked so that they do not practice medicine again. She said it could happen to anyone and this is the best way of ensuring that it does not happen to anyone else.
On Friday, 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 deaths of the three children has revealed that human deficiencies and systemic challenges contributed to the demise of those 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.
The first child who died was seven-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.