Professor Ray McMahon, a 68-year-old histopathologist originally from Galway, Ireland, died from an overdose of incorrect medication at Wythenshawe Hospital's Intensive Care Unit, his death was concluded by Zak Golombeck, Acting senior coroner in Manchester.
Wythenshawe Hospital is an NHS hospital operated by the Manchester University NHS Foundation Trust.
Dr. Katherine Adjukiewicz, representing the Manchester University NHS Foundation Trust, told Manchester Coroner's Court that a "cascade of errors" resulted in the death of Professor Ray. The incident has raised serious concerns about medication safety protocols within NHS hospitals.
Dr Sohail Munshi, the Trust's Joint Chief Medical Officer, issued a formal apology, stating: "Our care has fallen short of the high standard to which we aspire," according to BBC reports.
It is noted that Professor McMahon, who had dedicated his career to the Manchester University NHS Foundation Trust, was admitted to Wythenshawe Hospital by ambulance in February 2025. His symptoms included; Low-grade fever, Reduced appetite, and cough.
Initially treated for a suspected chest infection on a general ward, but as his condition deteriorated, he got transferred to an Acute Intensive Care Unit (AICU) on February 18, 2025.
Following consultation with the hospital's Infectious Diseases team, clinicians recommended starting Liposomal Amphotericin to treat a potential fungal respiratory infection if Professor McMahon's condition failed to improve.
However, a critical pharmacy error occurred when staff confused two different formulations of the antifungal medication:
Prescribed: Liposomal Amphotericin meant to be stored in fridge.
Administered: Non-liposomal Amphotericin/Fungizone (stored at room temperature)
These two amphotericin preparations are not clinically interchangeable. The incorrect formulation delivered a significantly higher dose than prescribed and also administered over one hour which resulted in a fatal overdose.
Professor McMahon suffered cardiac arrest as the medication infusion neared completion. Despite resuscitation attempts by medical staff, efforts to revive him were unsuccessful.
Tragically, the medication error was not identified until the following day, according to testimony heard at the coroner's court.
Claire McMahon, Professor McMahon's wife, delivered a powerful statement expressing the family's grief and disappointment:
"I and my family would like to express our extreme disappointment, distress, and sadness at what happened especially within the Trust where he worked for many years. Ray devoted his whole life to the NHS, but as a patient, he was failed by Wythenshawe Hospital. Our disappointment extends to Manchester University NHS Foundation Trust as an organization," as per BBC.
Dr. Munshi extended condolences on behalf of the Manchester University NHS Foundation Trust: "We again extend our deepest condolences to Professor MacMahon's family, friends, and colleagues during this incredibly difficult time."
The Trust has indicated it will conduct a thorough investigation into the medication error and implement additional safety protocols to prevent similar incidents.
Current evidence demonstrates significant safety differences between these formulations:
Nephrotoxicity (Kidney Damage): Liposomal amphotericin B is considerably less nephrotoxic than conventional amphotericin B. The liposomal formulation causes significantly fewer kidney complications. 1
Infusion-Related Reactions: Research indicates that liposomal amphotericin B is associated with fewer infusion-related adverse reactions compared to the conventional formulation. 1
These formulations have different dosing requirements and are stored differently in hospital pharmacies, making proper identification crucial for patient safety. The administration of conventional amphotericin B when liposomal formulation is prescribed can result in serious adverse events.
Reference:
1. Botero Aguirre JP, Restrepo Hamid AM. Amphotericin B deoxycholate versus liposomal amphotericin B: effects on kidney function. Cochrane Database Syst Rev. 2015;2015(11):CD010481. Published 2015 Nov 23. doi:10.1002/14651858.CD010481.pub2
(Rh/VK/MSM)
