Night shift at SA pathology lab scrapped over scientist fatigue concerns, inquest hears
The inquest of a man misdiagnosed with lung cancer has heard that the overnight ‘graveyard shift’ at the South African Institute of Pathology has been scrapped to keep tired scientists from making mistakes.
Key Point:
- Dennis Charles Jackson was misdiagnosed with lung cancer leading up to this death
- At the inquest, we are told that his biopsy sample was cross-contaminated at the SA Pathology Laboratory.
- I’m told his sample was processed by the night shift, which was then scrapped.
Broken Hill player Dennis Charles Jackson was mistakenly diagnosed with lung cancer before he died of pneumonia in January 2019.
Inquest investigating 67-year-old’s death previously heard His biopsy sample was cross-contaminated with another patient’s cancer tissue in the SA pathology laboratory.
Mr. Jackson then underwent unnecessary surgery to remove part of his lung, causing complications such as difficulty eating, drinking and swallowing.
Senior consultant pathologist Sophia Otto, now director of clinical services at SA Pathology, presented the evidence at the inquest on Friday afternoon.
She said Mr. Jackson’s biopsy samples were processed overnight, and after his death, the “cemetery shift” was discontinued to prevent fatigue and error among scientists.
Dr. Otto said he “continued to be concerned” that the unnamed scientist who worked with Mr. Jackson’s sample was prone to making mistakes in the middle of the night.
“I was worried that he might be tired, and of course there are very few people on the night shift, so I thought it might have disrupted the flow of work,” Dr. Otto said. rice field.
“I’m worried that the staff are wearing the same protective clothing.”
Earlier this week, we heard that the inquest was deemed “adequate” by the laboratory. Wiping forceps instead of “burning” them Used during acquisition and analysis of biopsy samples.
Caroline Smith, who worked at SA Pathology at the time, told the inquest that she was “surprised” to hear that lab equipment was wiped down between tests instead of being sterilized in a Bunsen burner.
Dr. Smith said it was not clear that the sample given to her was contaminated because there was no living tissue around.
She said her absence led to a second biopsy, unable to confirm what might prove aggressive cancer cells.
Dr. Smith said he outlined this in the body of the report, but could have been clearer.
“In retrospect, my report would have been better if it had been evaluated at the diagnostic line,” she said.
The court had previously heard that a doctor at the Royal Adelaide Hospital acted on her report, assuming that the samples showed invasive cancer cells, which led to unnecessary procedures.
Dr. Smith also told the inquest that when cross-contamination occurred in SA Pathology, staff were generally not given official communication.
“Many of my colleagues knew [Mr Jackson’s] There was no formal notification that a contamination event had occurred, which can only be described as a ‘corridor conversation,’ she said.
At the inquest, I hear that SA Pathology has introduced more checks and balances to prevent cross-contamination.
The inquest before Deputy State Coroner Ian White continues next week.
https://www.abc.net.au/news/2023-02-10/sa-pathology-gives-evidence-at-dennis-jackson-inquest/101958286 Night shift at SA pathology lab scrapped over scientist fatigue concerns, inquest hears
