New York

Harry Donnelly
Howard Beach, NY

Four-year-old Harry Donnelly was to have surgery to implant ear tubes and remove his adenoids, a common and routine operation to prevent chronic ear infections. During surgery, the operating table was moved which dislodged the breathing tube. No warning bells sounded and the anesthesiologist did not notice that the monitor had slipped off Harry's pinkie. Harry went without oxygen for 36 minutes and turned blue before passing away during the procedure.

Gene Goldstein

Eugene Goldstein was transferred from Stony Brook University Hospital to Southside Hospital in Bayshore, New York. His chemotherapy regimen to treat a Primary CNS lymphoma began at Stony Brook. That chemotherapy treatment was to be continued at Southside under the supervision of the oncology group. At the same time, Eugene would be placed in Southside's intensive physical therapy program for individuals with brain injuries, where he could receive therapy to improve his balance and walking ability that were temporarily impaired by the tumor.

Prior to receiving his first chemo treatment, Eugene thrived in his first week in the physical therapy program at Southside. He tolerated the four hour rigorous regiment of Physical therapy, occupational therapy, and speech therapy. The combination of the intensive therapy and the reduction of swelling from his tumor were helping him to regain his physical function rapidly.

The oncologists at Stony Brook discussed the chemotherapy protocol over the phone with the Southside oncologists, and a fax verifying the regimen was to follow. Apparently, either a fax was sent and misplaced, or was never sent, and the Southside oncologist proceeded to write orders for the oncology treatment based on what he had gleaned over the telephone. Gene was given seven days worth of a chemotherapy drug that he was not scheduled to receive until subsequent treatments, on top of the drugs called for during that treatment. This combination effectively obliterated his white blood cells, or leukocytes, which fight infection within the body. He went into septic shock on the seventh day of receiving the incorrect drug and never woke up.

August 2004