Pathologist died after hospital gave him wrong drug

The hospital has apologised for the fatal error

A "cascade of errors" led to the death of a highly respected histopathologist who was given the wrong drug at the health trust in Greater Manchester where he worked, an inquest heard.

Acting senior coroner in Manchester, Zak Golombeck, concluded Prof Ray McMahon, 68, died from an overdose of incorrect medication at Wythenshawe Hospital's intensive care unit and his death was contributed to by neglect.

Dr Katherine Ajdukiewicz, representing Manchester University NHS Foundation Trust, told Manchester Coroner's Court a "cascade of errors" led to his death.

Reading a statement on behalf of the family, his daughter Aoife said her dad was "failed" by the hospital.

Dr Sohail Munshi, the trust's joint chief medical officer, apologised, saying "our care has fallen short of the high standards to which we aspire".

Prof McMahon was working for the trust when he was taken to hospital by ambulance in February with a low-grade fever, reduced appetite and cough, the hearing was told.

He was treated for a chest infection, initially on a ward but was later transferred to the acute intensive care unit (AICU) on 18 February because he needed increased support.

A consultant in infectious diseases recommended starting liposomal amphotericin, the court heard, a medicine used to treat a potential fungal respiratory infection, if his condition did not improve.

'Wrong location'

However, in error, a preparation of liposomal amphotericin was prescribed that had to be stored in a fridge, when the medication the doctor needed was stored at room temperature on a shelf in the hospital pharmacy.

It resulted in the hospital's pharmacy looking in the wrong location and, in error, they misidentified non-lipid amphotericin (Fungizone) as the correct medicine, which was subsequently administered.

The two medicines are not interchangeable, the inquest was told, and the liposomal amphotericin dose was considerably larger and administered for one hour, resulting in a "significant overdose".

Prof McMahon suffered a cardiac arrest when the infusion was nearly complete and resuscitation attempts failed, the inquest heard.

This error was not discovered until the day after his death.

Prof McMahon's wife, Claire McMahon, said: "I and my family would like to express our extreme disappointment, distress and sadness at what happened especially within the trust that he'd worked for many years."

She added: "Ray devoted his whole life to the NHS but, as a patient, he was failed by Wythenshawe hospital.

"To know that both system and individual failures caused his death is devastating. Our disappointment extends to Manchester University NHS Foundation Trust as an organisation."

Dr Munshi said the trust "wished again to extend our deepest condolences to Prof McMahon's family, friends and colleagues at this incredibly difficult time".

He added the trust had undertaken a thorough investigation and said it would review "carefully" the coroner's conclusion.

Dr Munshi also said Prof McMahon was "a valued member of our staff for many years" and recognised "the significant contributions he made to the health service".