In 1975, Lee Duggins was an eight-year-old boy being treated for leukaemia with chemotherapy. Treatment required the injection of powerful drugs into both his veins (intravenous) and his spine (intrathecal). When Lee had to have both injections, they were done in the operating theatre. His mother was not allowed to be present. Tragically, a drug that should be given intravenously (vincristine) was accidentally given intrathecally. The mistake was not initially realised and Lee went home.

At first, when Lee got home he was okay. However, the next morning he was in considerable pain and was readmitted to hospital. Two days after the initial treatment, Lee and his family were told that something had gone wrong with the initial injection and the wrong drug had been given into his spine by mistake. Lee was given high-dose of steroids to try and suppress the inflammation. This was unsuccessful.

Over the next few days, Lee lost the use of all his limbs. He died in hospital six days later.

In 2001, Wayne Jowett was an 18-year-old teenager who lived in Nottingham. He was also being treated for leukaemia. The disease was in remission and his prognosis was good. Wayne and his grandmother had arrived unscheduled for his chemotherapy. To ensure that Wayne got his treatment, the staff squeezed him in to an already busy schedule. The same mistake, as in the case of Lee Duggins, was repeated.

The mistake was realised immediately. He was taken to the operating theatre where the surgeons tried to wash the drug out of his spine. Afterwards he was moved to the intensive care unit. Wayne, like Lee, died in hospital some time later.

Paul was a 23-year-old junior staff nurse working in a busy emergency department. Paul was asked by the sister in charge to give 60mg of oral codeine to the ‘abdo pain in bay 6’. He administered the drug without the prescription chart and without checking the patient’s name.

Paul came out of the cubicle and the sister informed him: ‘The abdo pain has been moved to bay 1, there’s a chest pain in there now.’ In the time it took Paul to obtain the drug keys and retrieve the drugs from the drug cupboard, the patient in bay 6 had been moved to another bay.

Paul realised he had made a critical error and immediately told the sister in charge. Paul then told the patient his mistake. The patient informed Paul he had a suspected allergy to codeine. The patient was immediately re-triaged and seen by a doctor. Fortunately, no harm came to the patient.