Coroner expands chemo inquest

An inquest into South Australia’s chemotherapy dosing bungle has been expanded after the death of a fourth victim.


Carol Bairnsfather, 70, died on Friday, prompting SA Deputy Coroner Anthony Schapel to include her in his investigation.

Mr Schapel was already inquiring into the deaths of Christopher McRae, 67, Johanna Pinxteren, 76, and Bronte Higham, 67, who were among 10 patients underdosed during their cancer treatment at two Adelaide hospitals between July 2014 and January 2015.

Mr McRae, Ms Pinxteren and Ms Higham all died from acute myeloid leukaemia.

At the opening of the inquest on Tuesday, counsel for some of the underdosed patients, Mark Griffin, also asked the coroner to expand the hearings further to consider the medical histories of the six patients still alive.

“Those records may provide useful information,” he said.

Mr Schapel will make a decision on Mr Griffin’s request during the course of his investigation but it has the support of the South Australian opposition.

Opposition health spokesman Stephen Wade called on the state government, through its representatives in court, not to oppose the move.

“It’s very important that this inquiry continues to get to the bottom of what led to this tragedy,” he said.

The inquest is considering what role the dosing bungle, the result of a typographical error, played in the four deaths.

During the course of their treatment the 10 affected patients received only a single daily dose of the chemotherapy drug Cytarabine when they should have received two.

Professor John Gibson, the head of haematology at the Royal Prince Alfred Hospital, told the inquest the frequency of the doses was important.

Prof Gibson, who prepared a report for the coroner and appeared as an expert witness, said while the impact on individual patients was difficult to predict, giving them a single daily dose was not “optimal”.

The inquest is continuing and comes after SA Health released a review of the bungle by the Australian Safety and Quality Commission that noted it involved “disturbing and indefensible” failures in clinical governance.

The report said staff involved at the two hospitals had little or no knowledge of SA Health’s incident management guidelines and failed to make an incident report soon enough.

SA Health accepted all six of the report’s recommendations, including better training for staff in incident management and handling, informing, and compensating patients more sensitively.