An inquest into the death of a man who had a ‘very rare’ reaction to chemotherapy treatment has revealed underlying problems at Pilgrim Hospital.
Graham Hurford, 56, of Glen Drive, Boston, had undertaken the ‘therapeutic’ treatment for cancer in the hope that he could be well enough to attend his daughter’s wedding.
However, following his first treatment at Pilgrim Hospital (pictured) on May 3, 2012, he suffered a ‘rare complication’ which led to his death on May 4.
Coroner Robert Forrest ruled on Thursday that Mr Hurford’s death was ‘an accident’ that was an unintended consequence of human actions’.
“Nobody wanted Graham to die as a result of his treatment,” he said.
“There’s always a possibility of an unforeseen outcome, nobody intended this to happen,” he added.
The inquest was originally adjourned following the revelation that Mr Hurford had received a second dose of Etoposide, one of the drugs used for treatment of cancer, on the day he had died.
However, at the inquest on Thursday, the coroner was told the extra dosage was only a small one, and would not have had an effect on Mr Hurford as ‘the die was cast’.
Following this, concerns were raised about the labelling of medicine bottles, particularly those used for cancer - which were supposed to be labelled with green biro.
The coroner was told by the former chief pharmacist Dr Jacqueline Miller that had an oncologist or chief pharmacist been present this would not have happened, however, she also admitted she thought staffing was too low.
She added labels had now been changed following the incident to make them clearer to read.
She also said the coroner she felt there was not enough ward based pharmacists at Pilgrim, and although she said it was fair to say ‘no principal pharmacist would say they have enough staff’ at Pilgrim Hospital (above) it was a ‘serious problem’.
An external expert, Dr Patricia Fisher, clinical director of Oncology in Sheffield, also raised issues from peer reviews by the hospitals.
The main one was in a self-review in 2011 where Pilgrim identified a need to update their communication systems to flag up to oncology specialists when cancer patients came into intensive care, yet by another peer review in 2013 this still had not been fully activated.
Dr Forrest said in light of the extra evidence revealed during the inquest, he would be sending out a letter to make United Lincolnshire Hospitals Trust aware of the changes that would ‘make the Pilgrim a hospital to be proud of’.