Northumbria Uni fined £400K after boffin's bad math gives students a near-killer caffeine high Northumbria University in England has been fined £400,000 ($503,000) after a botched experiment resulted in two students almost dying from caffeine overdose. Newcastle Crown Court issued the fine on Wednesday after hearing the case of two 20-year-old students who, as part of a study on the effects of the stimulant, were …
"“Both students have made good recoveries and both excelled in completing their degrees. There was a system in place but it was inadequate."
I get that systems fail from time to time but this case strikes me as a matter of gross negligence rather than a flawed testing methodology implied by the defence. £400k is a slap on the wrist for something of this gravity.
Reminds me of the various episodes(*) of "The Apprentice" where they end up spending 10x the amount to make their product (thus eliminating any possibility of profit) due to using far to much of the "very expensive ingredient"
(*) these Apprentice errors are so predictable and repeatable that I'm constantly amazed that contestants don't make wure they've watched all the previous series first so they can start each task with a quick run through what went wrong before
The Apprentice is all about people who are "Management material", you can't expect miracles from them like common sense.
The only ones that have had half a brain go out early as they aren't what we'd call "complete gobshites" who could wriggle their way out of any huge cockup and dump it all on someone else.
Without knowing the details, would it have been negligence if they were following a printed protocol exactly and it didn't tell them to double check the maths, and check the scales calibration and a host of other things?
Yes, a jobsworth giving somebody an overdose of a drug would have been negligent even if they'd have followed their instructions to the letter. They would also have been likely to be charged with (and found guilty of) manslaughter if the person they gave the overdose to died.
A risk assessment is not some arcane mystery, but a simple assessment of risks. In this case, it need not have taken more than a couple of lines.
1) What are the risks? Overdose, or erratic behaviour described on safety warnings on bottle.
Control measures.
A) Discover dose level at which point this activity becomes clinically dangerous. Not sure what this is? Ask a pharmacist or other responsible and competent adult.
B) Start with small drug dose (1/10th of $max limit = $quantity) and dose up to max limit in increments while recording changes in activity. The max limit shall be set to 80% of the clinical "safe" level for safety purposes and will not be exceeded.
C) Measure twice, cut dose once when dealing out drugs that you can overdose on. Person taking drug to be briefed on risks involved, OD symptoms and should check dose measurement.
These control measures devised in mere moments would have prevented the problem. This is not some form of weird issue either- it's a lack of basic responsibility and common sense on the part of supervising adults which almost led to fatalities. Pretty shocking advert for the university.
"(*) these Apprentice errors are so predictable and repeatable that I'm constantly amazed that contestants don't make wure they've watched all the previous series first so they can start each task with a quick run through what went wrong before"
Which is one of the reasons philosopher George Santayana is so famous: "Those who cannot remember the past are condemned to repeat it"
https://en.wikipedia.org/wiki/George_Santayana
Dave
I get that systems fail from time to time but this case strikes me as a matter of gross negligence rather than a flawed testing methodology implied by the defence.
Without knowing the details, would it have been negligence if they were following a printed protocol exactly and it didn't tell them to double check the maths, and check the scales calibration and a host of other things?
I should have thought the missing thing was a sanity check like "under no circumstances is a dose of more than 0.5g - much less than a teaspoon - to be given".
"Without knowing the details, would it have been negligence if they were following a printed protocol exactly and it didn't tell them to double check the maths, and check the scales calibration and a host of other things?"
1) "I was following orders" is not a defence for negligence (or incompetence or stupidity).
2) If the study didn't have the correct procedures in place, then the leaders, approvers and implementors of the study would be guilty of negligence.
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"they can't even recognise that they are two whole orders of magnitude wrong" --- Symon
THIS. Any remotely intelligent person should be able to estimate nearly anything to within two orders of magnitude. I used to ask my kids this sort of stuff all the time "see that container ship on the horizon -- how many containers do you think it's carrying? What do you guess its mass? How much paint would you need to paint the ship?"
It's one thing managers being shocked when you point out that no, you can't store 15 tonnes of healthcare records on the second floor because it's not strong enough, but the idea that a presumably postgrad researcher could make such a stupid mistake beggars belief.
That was my first reaction too - I have no idea of specifics of caffeine dosage, but hearing of a dose of 30 GRAMS of pure caffeine instantly blew ALL the fuses in my brain. Let's put if that way - would you consider putting 30g of SALT in your glass of juice? How about sugar...? No? Well then...
I remember my school maths & science teachers repeatedly telling us not to blindly trust calculators or computers (or humans!). Once you've got the answer you should always ask the question: "Does this number look/feel right?" e.g. Is it the right scale? Is it appropriate for the context of the problem?
Yeah, we teach "estimate before you calculate", which has been flipped more recently to "... before your computer calculates" for things like spreadsheet work.
Still, no matter what the experience of the person calculating, sometimes it all goes out of the window. I've mentioned in these hallowed forums before that I used to work with a very experienced senior engineer who used to have his old Sinclair Executive calculator as a sort of trophy on his desk. It reminded him off the times he dropped howling mistakes using it when it was the newest thing, before coming to his senses (or had them pointed out) and realising the answers went against years of experience. Although he and I barely overlapped in employment, the rest of the office used it as an example of the need to double-check everything the new design PC (single) printed out, before committing it to ink on the drawing board.
That was in building services engineering design - nothing like as critical or immediate as on the ground in medical experiments...
us not to blindly trust calculators or computers (or humans!). Once you've got the answer you should always ask the question: "Does this number look/feel right?"
It's the "GPS problem". If it says turn left, bell-end driver turns left. The fact that there's a No Entry sign, or a dirt track, or a pier end doesn't matter. Schools don't seem to teach common sense any more, and too many parents abdicated that duty a generation ago.
It's not even about using a calculator or even a piece of paper, consider these people were part of a research team looking at the effects of caffiene. One would think that they had the basic facts in place from the very beginning.
This is a case of negligence on the part of the lecturer and uni and rank stupidity on the part of the person/s administering the caffeine. 30 gm is alot of anything that might go into a cup of coffee, critical thinking or even thinking would be a useful part of the course.
I remember a friend of mine who is an IT teacher being roped in by the school to help cut costs of electricity. He and a Maths teacher who was also head of accounts, decided to work out how many lightbulbs they needed around the school.
They went into the main hall of the school, and the Maths teacher began counting each fixture... 1, 2, 3... Meanwhile my friend clocked that there were 8 rows of 5 fixtures, and said "40"!
The Maths bloke scowled, and said, "No, I want an accurate count, not an estimate"
I remember my school maths & science teachers repeatedly telling us not to blindly trust calculators or computers (or humans!).
In university I had a sie job doing remedial teaching* to secondary school pupils. Pretty often there would be one who'd forgotten his/her calculator, asking me for one. The less dim ones would quickly notice that RPN doesn't work like your average calculator, where others took up to five minutes before the lack of an 'equals' key penetrated their cranium. Five minutes of pushing buttons and writing down whatever had appeared in the display.
I doubt that doing magnitude checks and estimates stuck with those, and I can only hope they didn't end up in jobs where such skills are essential.
* it helps you explaining stuff too, as you have to switch back to their knowledge level.
How would anyone measuring out the dose think 30 g of caffeine wouldn't be a problem? Anybody with any knowledge should have simply known 30 g couldn't be correct. It's all fine and dandy being able to do sums, but my professors/teachers always pushed us to have a good guess as to how big the answer should be (To the point we could get bonus points on exams for questions we got wrong or didn't know if we could atleast give an accurate order of magnitude estimation.) It's all too easy to drop a zero somewhere and assume you are safe so knowing you expect an answer in the "one tenth" range instead of the "tens" range is a good skill to have.
I've still got my side rule in the attic, along with other things that speak of skills from a different pre-CAD age in engineering...
What astounds me is that tests like these were carried out on a seemingly unprepared fashion. Typical dosage tables should have been worked out beforehand, checked by someone qualified, and if possible administered if not by then at least in the presence of someone medically trained.
Giving it in orange juice would have the body thinking "ooh, it's a cream cake!", resulting in the mixture being absorbed into the blood more quickly, a bit like alcopops, for an event more immediate effect, reducing the window of opportunity to vomit much of the unabsorbed caffeine solution out as the mistake was realised (assuming the experimenters were that aware).
My exact thought.
Also, 30G will have some serious difficulty dissolving in a glass of orange juice. Caffeine is not that soluble in cold water.
If anything prior to that did not ring any alarm bells, the fact that 90% of it has remained on the bottom of the glass should have given some food for thought.
"How would anyone measuring out the dose think 30 g of caffeine wouldn't be a problem?"
Considering who they were and what they were doing, it's a mistake that should never have happened. But what most likely went through their minds was that the powder wasn't pure caffeine and the physical amount didn't look that different to the amount of instant coffee used per mug or even ground coffee going into an espresso or filter machine. That, added to the fat fingering all too common on mobile phone virtual keyboards lead to the mother of all brainfarts and no cross-check to catch it.
Peter Smith, defending. “Both students have made good recoveries and both excelled in completing their degrees
and
Judge Edward Bindloss noted: "Both were sportsmen and fit young men. Luckily for them and for everyone they were in the sort of physical shape that was able to deal safely with this large amount of caffeine.”
both seem to contradict the statement that one is still suffering after the overdose:
They each lost about 10kg in weight and struggled with sporting activities. They both eventually made a recovery, though Rosetta is reportedly suffering from short-term memory loss as a result.
I don't call short term memory loss a "good recovery".
"though Rosetta is reportedly suffering from short-term memory loss as a result."
Call me cynical but that possibly sounds like a statement the ambulance chasing lawyer has cooked up, where there's blame there's a fat pay check for fees. Psychological ailments are much harder to disprove than physical ones.
Having said that, that's one almighty fuck up but it does happen in the supposedly safe commercial pharma world. I used to work for an unnamed phamara co and someone cocked up the API dry weight calculation for batch formulation and the checker failed to spot it for a very expensive product, fortunately dissolution and strength testing of the finished product batch revealed too high a dose but £10M had to be flushed down the toilet as a result, due to the number of other tests it never reached the patient.
QC/QA & CGMP, that's why it's there.
"Call me cynical but that possibly sounds like a statement the ambulance chasing lawyer has cooked up, where there's blame there's a fat pay check for fees"
Maybe... But at the end of the day, this was a royal fuck up. A royal fuck which could, and should, have been prevented. The two lads were lucky to have survived at all, and they endured something which must have been horrific for them. It may even have caused some long term damage they don't know about yet. So, lawyers' fees or not, the uni deserves to pay every penny of that fine. And the two lads deserve each a decent enough payout to pay off their uni fees/ loans, and then some.
Really now...? Why, how do you reckon one recovers from "short term memory loss" (like the one after a bit too much alcohol) - by suddenly remembering stuff you can't remember the next morning, a week later or something? Or did you mix up "short-term memory loss" with "permanent loss of short-term memory"...?
students should be required to use slide rules for a while. You only get the mantissa, not the exponent. Yes, I am joking about this one (but only because there are other ways to teach that).
Students and their calculators, great fun (or not). My two pet peeves are:
- ignorance about the magnitude of the results (like here...)
- ignorance about the precision of the results. Say you measure a bike wheels diameter to calculate the circumference. You get 71cm. Student punches the number into the pocket calculator and writes down all 12 or whatever digits of the result, down to atomic nuclei sizes.
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