Investigations into the deaths of three children who died at the George-town Public Hospital (GPH) in January after being administered pre-chemotherapy drugs have found that the medication was incorrectly administered and standard operating procedures were not followed.
The findings were revealed at a press conference yesterday which included Chairperson of the GPH Board Kessaundra Alves, Deputy Chief Medical Officer Dr Karen Gordon-Boyle, and Director of Medical and Professional Services at the GPH Dr Fawcett Jeffrey.
Following the deaths of seven-year-old Curwayne Edwards, who died on January 14th, three-year-old Roshini Seegobin, of Enmore, East Coast Demerara, who died on January 18th and Sharezer Mendonca, 6, of Queenstown, Essequibo Coast, who died on January 24th, the GPH launched an investigation. The three had leukemia and were treated by the same team of doctors.
The Ministry of Public Health also launched its own investigation, which was led by Gordon-Boyle. The GPH’s investigation was spearheaded by Jeffrey.
Reading from a prepared statement in the hospital’s conference room yesterday, Alves said, “the Director of Medical and Professional Services submitted his final report to the CEO of the GPHC on 28th January 2019. That report concluded that human deficiencies and systemic challenges contributed to the demise of three infants.”
Gordon-Boyle, meanwhile, related that the protocols for the administering of the pre-chemotherapy drugs to the children were not adhered to. The drugs, which were previously not publicly named, were identified as vincristine and methotrexate. Following the deaths of the children, the hospital had announced that it was investigating and was terminating the use of the drugs.
Gordon-Boyle explained that the vincristine was administered intrathecally (administration for drugs via an injection into the spinal canal) rather than intravenously (administration of drugs through the vein with an injection).
“There are two medications; one is intravenous, and one is intrathecal and that was part of the finding, it was administered wrongfully,” she said.
Asked when did the hospital suspect something was amiss, she said that it was when the doctors recognised that the children’s health conditions were deteriorating. She said that the investigations revealed that when the medical practitioners checked the records, they realised that a mistake was made.
The three doctors who were directly involved in the incident were relieved of their duties and subsequently sent on administrative leave on January 29th and they currently remain on leave.
Alves, in her statement, said that the final report which was submitted to Chief Medical Officer Dr Shamdeo Persaud, concluded that “the GPHC protocols for the delivery of chemotherapy to infants were not adhered to and recommended a number of measures to strengthen that system and prevent a recurrence.”
Gordon-Boyle further explained that from her probe, limited staff in the paediatric oncology department contributed to the poor delivery of health care.
“The scenario that we were able to put together was lack of staffing and the few persons that were available stretching themselves between clinic, accident and emergency, ward rounds and administration of the chemotherapy, led to the administration of the chemotherapy being done without the senior person being present at all times,” she said.
She added that a senior doctor should have been present to administer or observe the administration of the drugs to ensure the protocols were being followed. “Understanding how the staff were pulled here, there and everywhere due to lack of staffing, they started to administer treatment without checking the standard operating process. Had they done that, we would not have been here today,” Gordon-Boyle indicated, while adding that a young doctor was involved in administering the pre-chemotherapy drugs.
Jeffrey also pointed out that the doctors erred by not following the standard operating protocols.
“When you are going to treat a patient, there are certain protocols you need to follow, there are road maps that you need to follow when you are going to administer any form of medical attention to a patient and what happened is that these road maps were not followed exactly as they should be and that is the reason we end up with the complication,” he said.
He noted that while it is unfortunate the hospital had to learn from this tragedy, they have learnt the importance of having junior staff being better supervised by their seniors. He further emphasised that it is important for doctors to “stick to the standard protocols for the management of all oncology in the hospital not only for the administration of chemotherapy drugs but all surgical procedure. Protocols are there and must be followed at all times.”
Compensation for Families
Asked if the hospital is looking to offer a compensation package to the affected families, both Alves and the GPH’s Chief Executive Officer George Lewis said that “all options” remain on the table.
Lewis stated that the hosting of the press conference to update the media on the findings of the investigation was one of many hey have to go through in dealing with the report. He explained “that the next stage would involve the hospital administrators engaging the board of directors, which will have the opportunity to study the report. All options remain on the table… In terms of me saying to you, today, we will be offering a compensation, I don’t have that authority.”
Alves pointed out that the report and its recommendations are yet to be discussed by the hospital’s board of directors and at the time, she was the only member to have reviewed the report. She added that she does not want to tie her directors to a timeframe on the discussions of the findings. In her statement, read at the beginning of the press conference, Alves said that the GPHC will soon commence the process of initiating action on the findings of the two reports.It was further pointed out that the families were officially informed of the findings yesterday. While they are still upset by the medical attention delivered to the now deceased children, they have asked the hospital to do everything in its power to prevent the situation from reoccurring, Alves said.
“The families are still upset. This is still a very perturbing situation. They had received some of this information before; it is just that we had to formally inform the families and they have expressed that they don’t want this to be a recurring situation, they will like us to make policies,” she said.
According to the GPH chairman, the families are interested in the manner in which the hospital will be disciplining the doctors who treated their children.
“They asked how we are going to treat the medical professionals involved in the accident. Contractually, we can determine who works at GPHC but who’s licenced to practice medicine in Guyana is a matter for the Medical Council of Guyana to handle,” Alves disclosed. She added that the hospital “have done as far as we could have, pending administrative leave, pending a review of these reports by the board of directors at the GPHC.”
The Ministry of Public Health, Board of Directors, Administration and staff of the GPHC deeply regret and formally apologise for this incident which resulted in passing of young Curwayne, Roshnie and Sharezer, Alves said in her closing statements.
