Dead man likely allergic to drug
A man died from anaphylactic shock after the Hutt Valley District Health Board failed to flag a possible allergy to medication in a national database, the Health and Disability Commissioner has found.
The commissioner’s report published on Monday said the health board’s system for recording information about allergies was inadequate, and that inconsistencies existed among different regional health authorities.
The patient died on holiday while being treated for a sore toe when he was given flucloxacillin intravenously at a health facility outside the Hutt Valley.
Three weeks earlier he had arrived by ambulance at Hutt Hospital emergency department after taking expired flucloxacillin tablets for the same ailment.
He had collapsed after experiencing itchy skin and shortness of breath.
While he was discharged with a possible allergy to the medication from Hutt Hospital, the Health And Disability Commissioner’s report said this was not recorded in any database. It was also unclear if the possible new allergy was communicated to him. He’d advised medical staff he didn’t have any allergies before his fatal treatment.
Deputy Health and Disability Commissioner Dr Vanessa Caldwell found the DHB to be in breach of the Code of Health and Disability Services Consumers’ Rights.
In a statement she said Hutt Valley, the man’s home DHB, had inadequate systems for ensuring that allergies were recorded in the National Medical Warning System (MWS), and had not properly communicated with the man’s general practice.
The National MWS is an alert service linked to patient National Health Index numbers. It is designed to warn health and disability services of known risks when making clinical decisions about individual patients. She was critical of the Emergency Department registrar’s documentation and communication of the man’s allergic reaction, and of his general practice which had been alerted of the man’s presentation to ED, but also failed to log the information.
Caldwell found there was inconsistency in how different health boards managed the MWS, and with information sharing between boards.
‘‘This case is an example of the weaknesses that exist within the current system. Without doubt issues with the national system contributed to these events, I nonetheless consider it vital for individual medical centres and DHBs to have their own adequate systems and processes in place for drug and medication allergies.’’
She recommended the Hutt Valley DHB provide the man’s family with a written apology.
Practical recommendations included the development of an ‘‘end-to-end’’ process for the ED and general hospital for when patients experience new actual or suspected medication allergies, a new discharge form, better education for staff around allergy reporting, and intermittent audits of whether policies relating to allergy reporting are being observed and are adequate.
Hutt Valley District Health Board chief medical officer John Tait said the DHB unreservedly accepted the Health and Disability Commissioner’s findings.
‘‘We acknowledge that we failed our patient and their whānau.’’
An apology had been made to the family, and working groups had been established to examine the areas singled out for improvement in the report.