In January 2001, 18-year-old Wayne Jowett died whilst receiving treatment for Leukaemia at the Queens Medical Centre, in my home city, Nottingham.
The chemotherapy consisted of two drugs: Cytosine, a drug that is injected directly into the spinal fluid and Vincristine, a drug that is injected into the patient’s blood.
A tragic accident
The doctor on duty that day, Dr Feda Mulhem, made a mistake, a mix up. Instead of injecting the Vincristine into Wayne’s vein he injected it into his spine.
It was a fatal mistake. Vincristine is a potent chemical, deadly when injected into the spine. The hospital staff soon noticed their mistake. Desperately they attempted to reverse the treatment but to no avail.
Slowly Wayne became paralysed. One month later he died. It was hopeless. In the end they decided to turn his breathing machine off.
Blame the Doctor
Of course the Doctor was to blame, Wayne was under his supervision.
Dr Mulhem was tried for manslaughter and ultimately received an eight month sentence after admitting the lesser charge of unlawful killing.
Wayne’s father was deeply unhappy: “Eight months for the killing of my son is absolutely ridiculous. It leaves a sour taste in my mouth.”
A series of failures
The tragedy occurred after a series of failures in a very complicated procedure:
- Wayne Jowett arrived late at the hospital. His normal Doctor had left
- Despite asking to be called, nobody contacted his physician when Wayne arrived
- The two drugs should have been delivered to the ward on separate days. They weren’t
- Both drugs were delivered in syringes that could be fitted to the spinal needle
- Dr Mulhem had never been told about Vincristine before
- Dr Mulhem didn’t read the medical chart properly
If a single one of these failures hadn’t happened then Wayne would be alive and well. But all the errors happened in a row. Accident prevention experts call it the Swiss Cheese Effect. All the holes lined up.
Yes the doctor made a mistake.
We all make mistakes.
The real tragedy
This is not the first or last time Vincristine has been administered incorrectly
- In 1976 Lee Duggins died in exactly the same way in England
- In 1989 Ryan Bishop died in exactly the same way in Canada
- In 2004 Guido Squillaci died in exactly the same way in Australia
It has happened over 30 times.
Blame and punishment is worse than useless
It is a natural human instinct but blaming people and punishing them doesn’t help. Everybody makes mistakes, punishing them after the event won’t stop that. It is as useful as closing the stable door after the horse has bolted.
But it is worse than that, scapegoating makes errors more likely:
- Apportioning blame scares people
- And because they are scared they won’t admit they made a mistake
- And because they don’t admit to the mistake nobody knows it happened
- And because nobody knows it happened the causes of the mistake don’t get fixed
Dr Mulhem isn’t going to make the same mistake again. But somebody else will.
A bad system will always beat a good person ~ Anon
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Hello James
Fantastic piece, the way you make your powerful point is powerful!
It reminds me of Deming and his philosophy/system especially:
Looking at the underlying ‘structure’ of the system to understand/alter the behaviour as opposed to the person’s;
Driving out fear so as to encourage/enable the honest/above board behaviour that is necessary for learning and improvement.
The challenge of course is to completely alter the human condition at least as far as I have experienced it in the UK. The command and control system with fear at the heart of it starts at home, makes a huge leap forward in school and then continues in/at work. And as humans we are blind to the system and systems behaviour: the human person is the entity that we either elevate to god/hero or the villain. That requires extensive education, training and reinforcement through practices.
Richard Rumelt talks of entropy and inertia as being fundamental law of human organisations. To bring about the kind of change you are advocating we need to deal with inertia to get change and later entropy to stop backsliding to the default ways of being human: blaming people.
Maz
Materials that are injected into the spinal fluid should be placed in readily identifiable vial by the manufacturer. Same with the syringe.
Absolutely right Kevin, they should. It is tragic that we have created a system that doesn’t support that way of thinking
James
Excellent post! I think that the quote “A bad system will beat a good person every time” is attributed to W. Edward Deming.
Thanks for the reference Bruno
Dr Mulhem, is my uncle..
And little years after this incident
His whole world collapsed
And he committed suicide
I miss him
And thank you for saying this
He really was a great man
I’m very sorry to hear that. How tragic.