In 1985, a shocking medical error at Jackson Memorial Hospital turned a routine eye operation into a fatal tragedy. That year, Miami photographer Bob East, 64, died after a formaldehyde-like chemical was mistakenly injected into his spine during surgery, instead of his own cerebrospinal fluid.
The anesthesiologist, Dr. Anthony Gyamfi, was performing a standard procedure meant to ease pressure around East’s brain before his cancer surgery. East was scheduled to have his right eye and surrounding bone removed to treat cancer, but what followed became one of Florida’s most notorious cases of medical malpractice.
A tragic case of mislabeling
According to The Washington Post, the surgical team had drawn 50 cubic centimeters of cerebrospinal fluid (CSF) before the procedure. That fluid was supposed to be reinjected later. However, in a tragic mix-up, Dr. Gyamfi instead picked up a syringe containing glutaraldehyde — a toxic chemical preservative used to disinfect or preserve tissue — and injected it into East’s spinal canal, instead.
The fatal confusion occurred because both the chemical and the spinal fluid were stored in similar containers, one of which had been mislabeled “CSF.” Glutaraldehyde was being kept in the operating room to preserve the cancerous tissue that would be removed during East’s eye surgery.
Moments after the injection, East went into convulsions and lost consciousness. Doctors tried to save him, but he fell into a coma and was declared brain-dead within hours. His wife later consented to remove life support.
A malpractice case for the ages
Hospital officials launched an investigation, calling it one of the most devastating medical mix-ups in hospital history. Their internal review found that the problem stemmed from poor labeling, unsafe chemical storage, and a lack of double-checking procedures during surgery.
At the time, hospital administrators called the incident “a tragic chain of human errors,” and vowed to tighten safety standards for handling biological samples and chemical agents in the operating room.
East’s family settled a medical malpractice lawsuit for a significant sum. The hospital suspended Dr. Gyamfi, and he surrendered his medical license to the state of Florida a few years later. Gyamfi expressed deep remorse, and while there were no immediate criminal charges, the case became widely cited in medical textbooks as an example of systemic failure rather than malicious intent.
