Findings on GPHC Cancer deaths… Doctors failed to follow protocol; shortage of trained medical personnel highlighted

Mar 09, 2019 News

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By Kemol King

The deaths of three children, all cancer patients, who received treatment at the Georgetown Public Hospital Corporation (GPHC) were due to failure by doctors to follow the protocol necessary for the administration of the drugs, Vincristine and Methotrexate.
At a press conference yesterday, the media was briefed on the investigations’ findings by a committee of officials from GPHC and the Ministry of Public Health. It was revealed by that committee that the failure to follow hospital protocol was due to a shortage of trained medical personnel.
The three patients were treated from the period January 3-4, 2019. Following the administration of these drugs, all three children suffered adverse reactions, which the medical staff of GPHC noticed on or around January 5, 2019. Kerwayne Edwards, 7, died on January 8 while in the Pediatric Ward, while Roshanie Seegobin, 3, and Sharezer Mendonca, 6, died on January 18 and 24, respectively, in the Intensive Care Unit (ICU). They were treated by the same team of medical doctors.
Chairperson of GPHC’s board of directors, Kesaundra Alves said that, following the passing of Edwards and the deterioration of the other two patients, the hospital’s administration launched an investigation into the circumstances surrounding the treatment of the patients, and their adverse reactions.
She said that GPHC had also immediately suspended the use of the two drugs as a precautionary measure. Doctor Fawcett Jeffrey, the Director of Medical and Professional Services, spearheaded this investigation through the Offices of the Deputy Chief Executive Officer, the Assistant Director of Nursing Services, Head of the Paediatric Department, the Pharmacy Manager, and other relevant departmental heads.
The investigation included the collection of statements from all parties, directly or indirectly involved, and other witnesses otherwise privy to personal information, Alves said.

Dr. Jeffrey submitted his final report to the Chief Executive Officer, George Lewis, on January 28, 2019.
Alves said that that report blamed “human deficiencies and systemic challenges” for the children’s deaths. Asked to expound on these deficiencies and challenges, the Hospital’s head of Quality Management, Ms. Holder, said that the hospital faces a shortage of staff, which at the time, caused the available personnel to be spread thinly across patients and duties.
As a result, a senior doctor was not there to supervise the administration of the medication, though this is what is considered ideal. The doctor who administered the drugs, administered Vincristine, an intravenous drug, intrathecally (to the spinal canal). This is what caused adverse reactions. It is important to note that the drug is marketed with instructions not to administer it intrathecally, because it is highly dangerous to do so.
Alves said that the committee executed a fact-finding mission through the review of each patient, their charts, and interviews with involved staff members of the hospital, as well as the parents of the patients.
She said that the committee submitted its preliminary report on February 22 and its final report to the Chief Medical Officer on February 28. It is this final report, which concluded that the GPHC protocols for the delivery of chemotherapy were not adhered to. She said that the report recommended a number of measures to prevent this from reoccurring.
Consequently, the medical practitioners involved were “relieved of their duties” and sent on administrative leave on January 29, pending further review of the report and possible disciplinary action. On the same day, the Chief Medical Officer, Dr. Shamdeo Persaud, acted on instructions from the Minister of Public Health, Volda Lawrence, to launch a second investigation into the circumstances surrounding the children’s deaths, in collaboration with the Pan American Health Organisation (PAHO). This time, Dr. Karen Gordon-Campbell, Deputy Chief Medical Officer, spearheaded the investigation. The committee noted that there were no differences in the findings of the two investigations.
Yesterday, officials from GPHC and the Ministry of Public Health formally informed the families of the patients on the findings of the investigations, and apologised for their deaths.
The committee informed the media that the next stage is for the hospital administration to engage with its Board of Directors about the reports. The board will decide whether disciplinary action is to be taken against the medical personnel involved, and whether the families will be compensated.
Additionally, the PAHO office in Guyana is currently conducting an evaluation to identify the additional deficiencies in terms of building the human resource capacity of the hospital.

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