Highly respected doctor died after receiving the wrong medicine

The inquest held at Manchester’s Coroners Court heard today (6 November 2025) that a “cascade of errors” led to the death of the highly respected histopathologist Professor Raymond McMahon, who was administered the wrong drug by staff at the very Trust which employed him.

Professor McMahon, 68, was still working for the Manchester University NHS Trust when in early February of this year, he became unwell with a low-grade fever, reduced appetite and cough. He was admitted via ambulance to Wythenshawe Hospital, Greater Manchester in the early hours of 14 February 2025. On arrival, he was stable but was admitted for further management. 

Ray, as he was known to his family and friends, received treatment for a chest infection, initially on one of the wards but was later transferred to the Acute Intensive Care Unit (AICU) on 18 February due to him requiring an increased level of support. The hospital’s consultant in infectious diseases recommended starting liposomal amphotericin, a medicine used to treat a potential fungal respiratory infection if his condition did not improve. The next day, a decision was made to give liposomal amphotericin and the medication was prescribed. However, in error, a preparation of liposomal amphotericin was prescribed which needed to be stored in the fridge, when in fact, the medication that Ray required is stored at room temperature on a shelf in the pharmacy.

This resulted in the hospital’s pharmacy looking in the wrong location and in error, they misidentified non-lipid amphotericin (Fungizone) as the correct medicine, which was subsequently administered to Ray. However, these two medicines are not interchangeable, and the dose of liposomal amphotericin is considerably larger than that of the non-lipid amphotericin (Fungizone), resulting in Ray receiving a significant overdose.

The wrong medication was administered to Ray for nearly one hour, and once the infusion was nearly complete, Ray’s condition deteriorated, and he suffered a cardiac arrest. Resuscitation attempts proved unsuccessful, and very sadly he died.

The error was not discovered until the day after Ray’s death.

Dr Katherine Adjukiewick, representing the Manchester NHS Foundation Trust, described a “cascade of errors” leading to the death of Dr McMahon.

Recording a narrative conclusion, acting senior coroner Zak Golombek said Ray died from following an overdose of the incorrect medication and that his death was contributed to by neglect.

Ray’s wife, Claire McMahon said: “I and my family would like to express our extreme disappointment, distress and sadness at what happened to Ray; especially within the Trust that he’d worked in for many years. Ray devoted his whole life to the NHS but as a patient, he was failed by Wythenshawe hospital. We are grateful for the thorough investigation undertaken by the hospital, but to know that both system and individual failures caused his death is devastating. Our disappointment extends to Manchester University NHS Foundation Trust as an organisation.”

Rachael Heyes, specialist medical negligence solicitor, JMW, who represented the McMahon family through the inquest process, said: “What happened to Ray was a complete tragedy.  There were multiple failings in his care, including the initial prescribing and the dispensing of the anti-fungal medication. I hope that the Trust can learn from what happened and ensure that the processes now in place are effective and no other patients are exposed to potentially serious harm in the future.”