Death of children: Report finds cancer drug given incorrectly

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The Georgetown Public Hospital Corporation (GPHC) on Friday said three children died at the hospital because the protocols for the delivery of chemotherapy to children was not administered correctly.

“These patients were treated by the same team of medical doctors and were administered the drugs vincristine and methotrexate (chemotherapy medications). Subsequent to the administration of these drugs, all three children suffered adverse reactions,” Chairman of the Board of Directors for GPHC, Dr. Kesaundra Alves said.

“When they (medical practitioners) realized that the patients were deteriorating and they checked, they realized a mistake was made; one drug was administered intrathecally (spinal) when it should have been administered intravenously (entering a vein)”, Dr. Gordon-Campbell, Deputy Chief Medical Officer, explained. 

The three children received the medication between January 3rd and 4th, 2019. On January 5, the doctors became aware that the medication was administered incorrectly.

Within hours of receiving the medication, the children started to experience strange symptoms and cried out for pain in their legs and arms.

Dr. Gordon-Campbell, Deputy Chief Medical Officer and Chairman of the Board of Directors for GPHC, Dr. Kesaundra Alves

They all became paralyzed and were placed on life support until their deaths.

On January 14, the first child, 7-year-old Curwayne Edwards, died. Then, four days later, it was three-year-old Roshini Seegobin of Enmore, East Coast Demerara (ECD). In another eight days, the third child, 6-year-old Sharezer Mendonca of Queenstown, Essequibo Coast, died.

The three doctors who were involved in administering the treatment to the children were subsequently sent on administrative leave on January 29, 2019, pending the outcome of the investigation.

“That report concluded that human deficiencies and systematic challenges contributed to the demise of the three infants,” Alves stated.

Dr. Karen Gordon-Campbell went on to explain what happened.

 “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 down without the senior person being present at all times.”

The protocol states what dosage to administer based on the child’s weight and where.

However, Chief Executive Officer for GPHC, Retired Brigadier George Lewis said the medical practitioners are on administrative leave pending further review of the report findings by the Hospital’s board of directors and “possible disciplinary actions if necessary.”

The decision of whether the doctors will be fired lies with the Medical Council of Guyana.

Dr. Gordon-Campbell said the findings from PAHO/WHO investigation were “pretty much the same” as that of GPHC and the Ministry of Public Health.

The Hospital board met the family of the three children on Friday morning to formally inform them of the findings of the report.

Director of Medical and Professional Service, Dr. Fawcett Jeffrey said they are protocols that have to be followed when any form of medical attention to any patient is administered but “these protocols were not followed exactly… and that is the reason why they ended up with the complication.”

Further, “what we learn from this incident is it is very important for us to have our staff there to supervise juniors…and that they stick to standard protocols for the management of all pathology, not only the use of chemotherapeutic drugs but any protocol,” Dr. Fawcett said.

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