Iodine dye error led to death of Nuthukumaru Nagarajah at Royal Free Hospital

Published: 14 October, 2010
by JOSIE HINTON

THE family of a pensioner who was mistakenly injected with iodine dye are to take legal action against the Royal Free Hospital after a coroner ruled the error contributed to his death.

St Pancras Coroner’s Court was told on Thursday how Nuthukumaru Nagarajah, 81, was administered with the dye during a CT scan at the Pond Street hospital in June, where he had been taken with suspected low blood sugar levels.

Iodine dye – also known as intravenous contrast fluid – is routinely used during scans to make organs show up more easily, but can place patients with impaired kidney function at increased risk of kidney failure.

Doctors treating the retired medical officer from Hendon, who had diabetes and chronic kidney disease, specifically requested that the dye not be used during  the scan. 

But when it was performed on June 25, a doctor misread the note and proceeded to administer the dye. The doctor, who was covering the nightshift for a colleague following her own working day, was “overstretched” after being left to deal with a backlog of cases single-handedly, the court heard.

Dr James Bell, a consultant radiographer at the Royal Free, told the inquest he requested the investigation be carried out without the dye but later learned there had been a mishap.

“I recorded those comments on the radiography information system before leaving the hospital with the expectation the scan would be done the next day,” he said. “From a radiology point of view it was an error on our part and we have since investigated the processes that allowed it to happen.”

Dr Bell said procedures surrounding CT scans have been overhauled since Mr Nagarajah’s death. Changes include a new form on which doctors must rate the patient’s kidney function before carrying out a scan, and more staff working out of hours.

Mr Nagarajah, who was also suffering from a number of other medical conditions including pneumonia and the effects of a recent heart attack, died 10 days later from multi-organ failure.

Coroner Dr Andrew Reid recorded a verdict of natural causes “to which accidentally given radiological contrast contributed”. 

Speaking outside the court, Mr Nagarajah’s son Siva said: “Prior to this he had a good quality of life. 

“He had 16 grandchildren who visited regularly and had just returned from Sri Lanka.

“We will be seeking legal action. The only comfort is that they have implemented changes so hopefully this will not happen to anyone else.”