End in sight for chemo bungle


AHPRA is winding up investigations into five hospital pharmacists and four doctors involved in the SA chemotherapy under-dosing affair – with some facing regulatory action

Over a period of six months between 2014 and 2015, five patients at the Royal Adelaide Hospital and five at Flinders Medical Centre in South Australia received only half the correct dose of Cytarabine for treatment for Acute Myeloid Leukaemia.

In response the SA Minister for Health and Ageing requested an independent review to be conducted.

The review panel found the under-dosing error had been caused by a series of “significant” clinical governance failures in the Royal Adelaide Hospital Haematology unit.

It also found that certain clinical staff had not complied with the SA Health incident management and open disclosure policies, by failing to:

  • Report and lodge the incidents;
  • Conduct timely and appropriate open disclosure with patients; and
  • Provide an immediate clinical response to patients who had been under dosed.

The panel recommended for the clinicians involved in the incident to be referred the AHPRA, which is winding up its investigation into the five pharmacists and four doctors involved in the bungle.

Eight investigations were finalised by the South Australian Board of the Medical Board of Australia and the Pharmacy Board of Australia with ‘no further action’ required, while one has so far resulted in a caution.

Three of the most complex matters are still under investigation and may result in regulatory action, according to AHPRA.

“These matters have been extremely distressing for the patients and families involved,” said AHPRA in a statement.

“Patients should feel safe in the healthcare they receive. While our investigations are independent, we are working with our counterparts at SA Health to achieve system-wide improvements in clinical care.

“We cannot comment further to protect the integrity of legal processes and any current or future action we may take.”

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