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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Just remembered this old chestnut:
An engineer, a pysicist and a mathematician are each given the same task: open a can of beans without any tools.
The engineer picks up the can and hurls it against the wall as hard as he can. The can cracks open.
The pysicist picks up the can, tries to estimate the can's size and weight, does a few quick calculations and hurls the can against the wall as hard as he can at the optimal angle from the optimal distance.
The mathematician picks up the can and says "let's assume this can is open..."
In a situation like this wouldnt it be better to work out the dosage beforehand in an low pressure environment and get confirmation from a colleage, rather than do it on the fly?
I imagine the researcher's heart rate was probably nearing that of the subjects when they realised what they had done.
30 grams is a horking mountain of powder. Perhaps the responsible person's arithmetic skills were shy, but common sense should have told him to re-check. I remember extracting the tea-equivalent of caffeine in first year Chemistry lab, and what surprised me was how much white powder came out of what would have been about 5 cups of tea. Thank goodness nobody croaked.
I estimate that at the peak of my coffee habit I was ingesting 7 or 8 grammes of caffeine per day. Even now, I'll occasionally drink a mug from a 3-shot espresso maker, which probably has close to a gramme of caffeine. (300mg in an espresso shot seems about right.)
Never did me any harm. (Twitches.)
I always do a mental approximation of my shop purchases so I can have the right order of money ready at the till. Then I always check the receipt afterwards for missed items or mistakes on manual price entries. At least once a month there is an error either at the till or in the shelf pricing.
One day the total was higher than expected. Only having £5 in my wallet I removed some items - then some more. Finally there was nothing on the conveyor - and the till still said £5. It was the first transaction of the day and the till had accidentally been primed with that amount.
Even with bar codes you can get doubled entries. The most interesting was a misread of the bar code that gave a more expensive product. Fortunately speciality Xmas puddings are not on the shelves in the middle of a northern summer. No amount of till rescanning could reproduce the misread to cancel the item.
> I always do a mental approximation of my shop purchases so I can have the right order of money ready at the till. Then I always check the receipt afterwards for missed items or mistakes on manual price entries. At least once a month there is an error either at the till or in the shelf pricing.
My ex could remember the price of *every item* in a full trolley and would stop the cashier immediately if something came up with a different price. It happened quite often.
Some shops are worse than others for accurate shelf pricing: Super Drug - I'm looking at you. They have a remarkable ability to discount the price on the shelf label but mysteriously forget to update the tills. No memory super-powers required it's so blatant.
Even with bar codes you can get doubled entries. The most interesting was a misread of the bar code that gave a more expensive product.
my favourite was a bottle of high end single malt, normally £35-£40 a bottle rang up at £18 at the till, the guy at the checkout was saying how expensive that was and was it really worth it drinking something that cost so much... I'd have run back and picked up 2-3 more bottles if I'd had the guts.
" I'd have run back and picked up 2-3 more bottles if I'd had the guts."
I always query if the price rings up lower than the shelf price. If the assistant says "that's what's on the computer" - then I happily accept the unexpected bonus. Sometimes it is a special offer that hasn't been marked - or the offer label has fallen off the shelf.
I once complained about not getting the multi-buy shelf offer. Instead of giving me just the difference the Waitrose floor manager gave me a fiver. I protested that it was far too much - and eventually the excess went into a charity box.
One day I wanted a particular good-ish wine - but the labelled rack contained something different. A query established they had none - and the misleading label was removed. I bought a similar priced one and went to the check-out. The floor manager came across and told the assistant to ring it up as a goodwill gesture.
If a store plays fair with me then I play fair with them - and they will retain my custom.
The quantity of caffeine largely seems to have arisen from an unchecked switch from commercial tablets (probably pro plus) which have other things in them to pure powder possibly from a chemical supplier. The catalogue of errors begins with those devising the experiment not being competent and understanding what they are purchasing right through to whoever authorised the ethics for this experiment in the first place. The phone as a calculator is less of a problem in itself than an indicator of the complete lack of thought which went into this.
My students actually do this experiment as part of applied science btec! The risk assessment however says only commercial products to be used and put a limit on it.
So many potential checkpoints in this experiment seem to have been missed. As others have already pointed out, everything from not estimating the dosage result before performing the (inaccurate) calculation, the point that 30g of caffeine is a BIG pile of powder, the fact that it would be unpleasant for the testers to drink (and would have taken a lot of mixing, due to not readily dissolving), all should have triggered alarm bells with the students performing the test, yet they seem to have blundered on regardless.
When building anything, my father in law always says "measure twice, cut once". A similar philosophy here would have hopefully prevented this incident occurring in the first place.
But, seriously, I'm glad they're okay. There was a time when a caffeine pill - 2 cups of coffeee - would tie my empty stomach in knots. I can't imagine what "twice a lethal dose" is like.
First let me say I work in medical research governance for a large NHS University Hospital, and am based in a University.
I think I can see part of the problem here: "enrolled in a March 2015 sports science experiment on the effects of caffeine on exercise.". Specifically the "sports science experiment".
As the participants were probably recruited directly from the student population I would assume that being a university the study would have been through an internal university approval process involving some kind of university Research Ethics Committee (REC) but probably no external scrutiny and possibly without input from a pharmacist or a medically qualified person.
Had the study been run under a medical school and had NHS involvement (which happens a lot) then it would have been a whole different thing.
This study would have needed approval by the Health Research Authority, an NHS REC, which would have been made up of medically qualified people. Also as the caffeine/orange juice mixture would be defined as a Investigational Medicinal Product (IMP), basically a drug, so the study would have also required approval from The Medicines and Healthcare products Regulatory Agency (MHRA) as well.
The IMP would have had to been made by a qualified pharmacist working in a pharmacy that had a licence to manufacture the IMP with very strict SOP's in place as to how the IMP is made, stored, distributed, used and destroyed if not used.
I just find it mindbogglingly unbelievable that this study would have been allowed to be conducted under the circumstances it seems to have been run!
PS To put on my pedants hat "...were mistakenly given as much caffeine as what's in 300 standard cups of coffee." seems like the author studied at the Ernest Wise School of English!
PPS The term IMP always makes me think of the great Terry Pratchett and the various Discword devices that have actual imp's inside them, like Twoflowers camera or Sam Vimes organiser. So every time I read a research protocol and read about what's going to be done to/with the IMP it always brings a smile to my face.
I worked it out the other day based on an average UK male body mass of 84kg and an LD50 of 200 milligrams per kilogram. It comes out at 16.8g
LD50 is the level at which half of the test subjects died. So these two are bloody lucky indeed, having taken nearly double that. What are the odds?
Sixteen to one, if my maths & stats is any good.
It's not like you give the lab animals medical treatment when measuring the LD50.
Also, I'd presume that noone (except possibly Mengele and his North Korean equivalents, but they don't publish their results) has actually done studies into the LD50 of caffeine in humans, so any numbers are gonna be an extrapolation from animal studies combined with case studies of human intoxications.
I'd guess that most caffeine poisonings anywhere near this range is suicide attempts,and typically that would be caffeine pills and not pure powder, which makes it hard to get close to this dose.
A good point @ Patrickstar. Medical treatment... but the LD50 for caffeine in humans is a mixture of animal studies and "anecdotal" accidental poisonings. I expect these two will now form part of those figures. They would have presumably died had treatment not been given.
>but the LD50 for caffeine in humans is a mixture of animal studies and "anecdotal" accidental poisonings
What other drugs (legal and illegal) to take and food you eat can also greatly influence caffeine metabolism as it's metabolised by a CYP450 enzyme (CYP1A2) in the liver.
"I expect these two will now form part of those figures."
On the assumption that they'd have died without swift medical intervention, presumably they will provide an upper bound on the true figure. Ironically, they will be the kind of "back-of-the-envelope" figure of which these researchers were so tragically unaware.
"While administering the powdered caffeine for the study, a staff researcher had calculated the dosages on a mobile phone and missed a decimal point in the calculations. As a result, they both ended up getting 30g of the stimulant mixed into orange juice and water rather than the intended 0.3g. One cup of coffee typically has 0.1g of caffeine."
Who was checking the calculations to make sure they were correct?
that the dose wasn't pre-calculated based on population averages and simply adjusted once the subject's body mass was measured.
I used to do this sort of shit as a student during my first two years. It was mainly the RAF who were interested in the effects of various things that their pilots might get up to. I had to, on various occasions, not all at the same time, eat a 1kg bar of Dairy Milk / a carob alternative with a clothes peg on my nose so I couldn't tell the difference, drink 6 cups of tea (caffeinated or decaffeinated) in the hour prior to the test, drink 4 cups of coffee likewise, starve myself of all but water for 24 hours prior to the test, eat normally for 24 hours or overeat (they gave me a menu and a box of food for these), sleep for varying numbers of hours in the 48 hours before a standard reactions test and, for want of a better word, copulate at least 6 times in the 24 hours before the test, do it just the once, or abstain.
And when you're paid to take part in experiments like that as an impoverished student, you tend to take them up on the offer.
Caffeine is a carcinogen and toxin. You buy it, it comes shipped to you from a chemical supplier with a MSDS, which they are duty bound to provide, and you are duty bound to read thoroughly. The two de facto chemical suppliers to UK universities are Alfa Aeser and VWR, both of whom shit themselves at the thought of *not* sending you a full paper copy of the relevant paperwork.
MSDS that meet the requirements of CLP and GHS contain a rather fullsome toxicity section, which explains clearly the LD50 of the material in question.
If you aren't capable of reading a MSDS, you shouldn't be in a University research department.
If you ignore the requirement to read a MSDS you shouldn't be in a University research department.
If you don't understand what LD50 means, you shouldn't be in a University research department.
If you can't perform basic arithmetic, you shouldn't be in a University research department.
None of this is even slightly open to debate.
Yeshua fucking Christ.
Slightly OT but hell...
Answers to "What is two plus two" over the decades
1956: "Four, of course"
1966: "Three, but it's the method that is important"
1976: "Just a second while I get out my calculator"
1986: "Just a second while I open the 'calculator' window"
1996: "Just a second while I check the addition home page"
(Seen in New Scientist yonks ago...)
This is why physicians really shouldn't be allowed to do research. Anyone with any common sense knows the difference between 300 milligrams of powder and 30 g of powder. It should have also been apparent that something is wrong when it wouldn't all dissolve in the orange juice.
This is similar to the nurse that gave a near-lethal dose of morphine to someone I knew. Despite giving morphine for years, the nurse didn't blink twice when she calculated a dose that wouldn't fit in any of the syringes on the floor. She just went to another floor to find a large enough syringe, then injected 10x the required amount.
I collected my regular prescription from the local pharmacy - plus an additional pill that the doctor had prescribed.
It was only when cutting up the foil into daily doses that I noticed the new pill was twice the strength of the prescription. Took them back and the head pharmacist was not a happy bunny. Not sure if they had a double-check system - but I always check carefully now before I leave the shop.
Is it any fucking wonder the world in general backs away from science and distrusts it when the idiots currently wearing the lab coats can't check their sums before committing them into immortality?
First bleeding spreadsheets that were screenshotted and published without running a finger down the columns and doing some mental arithmetic to see that the displayed information wasn't garbage, and now this twattery.
Everyone concerned should be made to stand in the market place wearing a pointy hat with a "D" on it for extreme unscientific stupidity and sporting sandwich boards declaring "I have a University Education and I can't do simple arithmetic".
Surely in an experiment like this, the doses would have been pre-calculated and checked. So they knew exactly what they would be feeding them before the experiment even started.
Students 1 and 2 = 0.01g
Students 3 and 4 = 0.05g
Students 5 and 6 = 0.1g
Students 7 and 8 = 0.2g
Students 9 and 10 = 30g
Anyone spot the odd one out?
In the medical experiments where I was a lab rat, the entire protocol was always worked out in advance - except for the take two aspirins and pee occasionally in your plastic bottle for three hours experiment on aspirin metabolism. We ate our aspirins, and all sat watching videos, playing video games, snooker or reading magazines. And hearing stories from the two guys who had been on the early viagra tests, which had an unfortunate result on one poor guy for almost a week apparently, to earn our £30 (it was 15 years ago). Very relaxing. Until the nurse stormed in around the 2.5 hour mark and said "None of you lot have given a single pee sample yet! Drink a cup of water now or we will have no samples at all. And might not pay unless you have a piss soon!"
Two cups of water each and 15 minutes later there were queues at the cubicles - there were 40 or so of us that day.
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