A junior doctor who gave an elderly man the wrong drug for a stroke has been found to have breached patient rights.
Health and Disability Commissioner Anthony Hill said, in a decision today, that the unnamed house officer made significant errors of judgment in the case in late 2013.
The 77-year-old man arrived at the emergency department at a regional hospital in Nelson-Marlborough after having had an ischaemic stroke.
It was correctly decided to give him a clot-busting, or thrombolytic, drug - but the correct one of these, alteplase, was not available in the emergency department (ED).
The house officer, known as Dr B, opted instead for another in this class of drugs, tenecteplase, which is only used in this country for heart-attack and not stroke patients.
The report said Dr B not only gave the patient the wrong drug for his condition, but a dose more than twice what he should have received, and with the wrong method of administration - 10 percent followed by an infusion, rather than the required single dose all at once.
When Dr B was part of the way through administering the drug, she was told that alteplase was available in the intensive care department, where hospital guidelines dictated it was meant to be administered, and where staff were ready to do that.
Dr B consulted a senior doctor at this point by phone and it was decided to continue with the tenecteplase.
The patient, Mr A, deteriorated rapidly after receiving the drug and died a few days later from a brain haemorrhage.
Mr Hill said Dr B made significant errors of judgement in failing to transfer Mr A to the Intensive Care Unit, in deciding to prescribe tenecteplase at the dose and via the mode of administration used, and in failing to discuss the use of tenecteplase with the senior consultant, Dr C, by phone.
She also did not discuss with her senior her decision to give Mr A treatment in the ED, or to prescribe tenecteplase at the dose and in the way she did, Mr Hill said.
Problems with guidelines
There were also inadequacies in the Nelson-Marlborough District Health Board's stroke thrombolysis "pathway" or procedure guidelines.
This contributed to "evident confusion amongst nursing staff about the correct process for administering thrombolysis, and Dr B had not been orientated to the Stroke Thrombolysis Pathway adequately".
The lack of clarity in the relevant DHB policy appeared to have contributed to Dr B's mistake, Mr Hill said.
He also criticised the senior consultant, Dr C, for failing to provide either the patient or his wife with a timely and clear explanation about the medication error.
According to the report, Mr A's wife complained to Mr Hill about the care her husband received, and said she was "shocked by what she was told, but she was not provided with any information about her right to complain to HDC (Health and Disability Commissioner) until the hospital sent her a standard letter asking her to rate the standard of care provided by the hospital".
Senior staffing increased
Nelson-Marlborough DHB chief medical officer Nick Baker told Checkpoint with John Campbell changes had been made.
"We've increased the senior staffing that's available, and maybe one of the most exciting initiatives that we're just about to undertake is the pilot of a telestroke service, recognising the challenges of getting timely care.
"You can only do this kind of treatment if you get there within a few hours of the initial event."