THE Georgetown Public Hospital Corporation (GPHC) on Friday said that the deaths of three children at the institution recently were caused by the misadministration of a drug given as part of the chemotherapy treatment.

Seven-year-old Curwayne Edwards succumbed on January 14; Roshani Seegobin, three, died on January 18 and Sharezer Mendonca, six, passed away on January 24. The trio succumbed after receiving treatment for leukemia, a form of cancer. After the first two deaths, the GPHC confirmed that an investigation had been launched. On Friday, Chairman of the Board of Directors for GPHC, Dr. Kesaundra Alves shared with members of the media the findings of the completed investigation, submitted by the Director of Medical and Professional Services, Dr. Fawcett Jeffrey on January 28.

“These patients were treated by the same team of medical doctors and were all administered the drugs vincristine and methotrexate [drugs given as part of the chemotherapy treatment],” Dr. Alves said. “That report concluded that human deficiencies and systemic challenges contributed to the demise of the three infants.” “When I say human deficiencies, I simply mean that when you’re going to treat a patient there are protocols that you need to follow, there are roadmaps that you need to follow when you are going to administer any form of medical attention to a patient and what happened [was] that these roadmaps and protocols were not followed exactly as they should be and that’s the reason why we ended up with the complication,” Dr. Jeffrey, who was present at the engagement, explained.

As shared by Minister of Public Health, Volda Lawrence, earlier, the Ministry of Public Health would conduct its own independent investigation. According to Alves, the final report for this investigation was submitted to the Chief Medical Officer (CMO), Shamdeo Persaud, on February 28. “That final report concluded that the GPHC protocols for the delivery of chemotherapy to infants were not adhered to and recommended a number of measures to strengthen the system and prevent a recurrence,” Alves said.

The ministry’s investigation was led by Deputy CMO, Dr. Karen Gordon-Campbell, who indicated that the report done by the ministry yielded similar findings to the one done by the GPHC, i.e., that the misadministration of the drugs coupled with the lack of supervision were to be blamed for the deaths. “It wasn’t a question of the dosage; the administration – in terms of where it was administered – was done incorrectly,” the deputy CMO said. In fact, she disclosed: “One drug [Vincristine] was administered intrathecally [injected to the spine] when it should have been administered intravenously [or injected into the veins].”

Additionally, it was discovered that the medication was also administered incorrectly, without the supervision of a senior doctor. “The scenario that we were able to put together was lack of staffing and the few persons that were available were stretching themselves between clinic, accident and emergency, ward rounds and the administration of the chemotherapy, led to the administration of the chemotherapy being done without the senior person being present at all times,” Dr. Gordon- Campbell explained.

Alves explained that during the investigation, the medical practitioners directly involved in the incident were relieved of their duties, and then on January 29, were sent on administrative leave. These practitioners remain on administrative leave, since according to Alves, that is the extent to which the GPHC can act now. The reports will now be presented to the hospital’s board, which will then have to determine the way forward.
“The GPHC will shortly commence the process of initiating action following the findings of the two reports.” She noted however that further disciplinary action, i.e. revoking the practitioners’ licences, would have to be taken by the Guyana Medical council. And in fact, Chief Executive Officer (CEO) of the GPHC, Brigadier (ret’d) George Lewis, indicated that the council has already requested the report of the investigation.

BETTER SYSTEMS

The shortage of staff that contributed to the death of the children is a challenge which Lewis has acknowledged. Cognisant of the staffing deficiencies, Lewis shared that the hospital opened up application for paediatricians to join the staff and subsequently two persons were hired.
Besides, he shared that GPHC is working in conjunction with the MoPH to ensure that the hospital’s facilities and resources are bolstered. Towards that end, an evaluation is currently being done by the local PAHO office to help identify additional deficiencies in the hospital’s human capacity. “The review [from PAHO] is not for the paediatric oncology department, but it’s for oncology in general and hopefully at the end of the process we will be better equipped, better prepared and be able to provide better healthcare,” Lewis said.

COMPENSATION

When questioned about compensation for the families who lost their loved ones, Lewis also indicated that presently “all options are on the table” but that is also something that the hospital’s board would need to discuss.
So far however, the hospital has not been met with any legal action brought by the families of the deceased. However, the family of young Mendonca has requested, through their lawyers, to have the medical reports for the girl. Lewis indicated that the lawyer was advised that those medical reports would only be provided when the investigation was concluded and said that the hospital spoke with this family and committed to sharing the reports.
He also indicated that the hospital has formally informed the families of the findings of the investigation. “The MoPH, the board of directors, administration and staff of the GPHC deeply regret and formally apologise for this incident which resulted in [the] passing of young Curwayne, Roshnie and Shareezer,” Alves said. “The GPHC commits to continuously striving to improve our ability to deliver quality healthcare.”