The Coroner’s report found that Gary died as a result of lung damage caused by bleomycin toxicity and also as a result of the overdose of the bleomycin.
Gary was treated in University College London Hospitals NHS Trust (UCLH) after being diagnosed with testicular cancer. He was told that he had a 60% chance of survival and was offered a place on the medical trial which doctors told him would increase this. Gary and his family agreed to this believing his chances of survival would be greater and that he would receive a better level of care.
The trial, called TE23, was testing whether a combination of five existing chemotherapy drugs was better at treating testicular cancer than the standard treatment of three drugs. From June until mid-September 2007 he made regular trips to UCLH in central London, to receive the drugs. On seven occasions between July and September last year, he received 30,000 units of one of the drugs, bleomycin, instead of 15,000.
Gary eventually developed a dry cough, a symptom of lung damage, caused by bleomycin. The inquest heard that the cough should have been recognised by doctors and nurses as a warning sign that the bleomycin was damaging his lungs, however, despite the cough, he was given a final incorrect dose of bleomycin. Eventually he became so ill that he was transferred to intensive care. He died on 14th October 2007.
The Coroner’s report concluded that Gary died as a result of an accidental adverse healthcare event, caused by a prescribing error to which the set up of an electronic prescribing system contributed.
Mark Bowman represented Gary Foster’s family at the inquest. He is also representing the family in a medical negligence claim against UCLH. UCLH has been served with a letter of claim and a letter of response is awaited. The claim has been passed by UCLH to the NHS Litigation Authority.
Gary’s mother, Colleen Foster said:
"We were told by the hospital not to worry, that testicular cancer was curable and that taking part in this trial would further increase Gary’s chances of survival. Instead, the drugs that were supposed to save his life were killing him. An overdose gives the impression that it was a one-off. It was seven times. Every week my poor Gary was going into hospital, we thought he was getting better but, actually, he was being slowly poisoned and poisoned to death."
"This tragic case highlights the potential dangers involved in any form of clinical trial. Such trials need to be set up, regulated, monitored and administered with the utmost scrutiny, to avoid others suffering the fatal consequences that befell Gary Foster."
UCLH has suspended the TE23 trial.
This case received a lot of press and media interest. It was reported on BBC Evening News and ITV's London Tonight on 22 September. You can read about it in The Times, The Telegraph, BBC.
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