Press Release – Office of the Health and Disability Commissioner Deputy Health and Disability Commissioner Kevin Allan today released a report finding a locum GP in breach of the Code of Health and Disability Services Consumers Rights (the Code) for undertaking an inadequate assessment of a man in her care. The man, …
Deputy Health and Disability Commissioner Kevin Allan today released a report finding a locum GP in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for undertaking an inadequate assessment of a man in her care.
The man, in his sixties, had a history of diabetes, hypertension, and heart disease. He saw a locum GP because he’d been having indigestion and a lack of appetite for several months, had a fever and was exhausted.
Monday, 26 July 2021, 2:06 pm
Deputy Health and Disability Commissioner Kevin Allan
today released a report finding a locum GP in breach of the
Code of Health and Disability Services Consumers’ Rights
(the Code) for undertaking an inadequate assessment of a man
in her care.
The man, in his sixties, had a history of
diabetes, hypertension, and heart disease. He saw a locum GP
because he’d been having indigestion and a lack of
appetite for several months, had a fever and was
exhausted.
The locum GP discussed with the man his
symptoms, recent medical notes and medications, and
diagnosed him with gastritis. She prescribed medication and
Monday, 5 July 2021, 2:08 pm
Deputy Health and Disability Commissioner Kevin Allan
today released a report finding a district health board in
breach of the Code of Health and Disability Services
Consumers’ Rights (the Code) for failures in its care of a
woman with an ongoing dental infection.
Following an
unsuccessful root canal treatment, the woman went to the
Capital and Coast District Health Board (CCDHB) emergency
department with facial swelling and worsening pain. Her
tooth was extracted and she was admitted to the emergency
department observation unit overnight before being
discharged. She was given antibiotics and a follow-up
appointment was arranged.
At some point after surgery, the boy’s hip re-dislocated. In the meantime, Dr A saw the toddler multiple times to check his progress and change his cast. His hip was X-rayed in February, April, and May, but Dr A did not recognise the dislocation, despite radiologists who reviewed the scans flagging changes to the hip, Allan’s report said. Dr A told the commissioner he did not see any of the radiologists’ reports.
Unsplash
The boy underwent further surgery in February 2019 once the dislocation was recognised, and remained in a cast for four months afterwards. (File photo) The boy’s mum raised concerns at the time that her son was not standing on his left leg, and had taken over four months to start to walk with a “pronounced limp”.
It was also the pharmacist manager s – Ms B – first day. While another pharmacist, Ms C, processed the prescription, Ms B – who had more than 20 years’ experience – undertook the final check.
Stuff
The error was only noticed six months after the medication was dispensed. Sumatriptan and sertraline were next to each other on the shelf, and Ms B did not notice sertraline had been dispensed instead. It was six months before the school nurse alerted the pharmacy to the mix-up. Once the error was discovered, Ms B asked the school nurse to ask Mrs A to return the medication. She provided a verbal apology after being informed of the error, notified the Pharmaceutical Defence Authority and contacted Miss A’s GP.