The woman suffered a severe anaphylactic shock reaction and died at Whangārei hospital after she was given
A woman in her 80s has died in hospital care after she was given penicillin following a surgery – despite detailing that she was severely allergic.
In a decision by the Health and Disability Commissioner, they found Northland District Health Board and three medical staff breached the Code of Health and Disability Services Consumer’s Rights (the Code) after prescribing and administering antibiotics the woman was allergic to.
The woman, Mrs A, had been admitted to Whangārei Hospital in 2020 following an elective surgery, at which time her severe penicillin allergy was clearly documented, according to the report.
She was transferred to a different ward, where a senior medical officer directed the house officer to change her antibiotic to Augmentin, which is a penicillin based antibiotic.
The doctors who made the change didn’t inform Mrs A of the antibiotic change and didn’t properly check whether she had adverse reactions or allergies before prescribing, and administering it.
She suffered a severe anaphylactic shock reaction and died.
Health and Disability Commissioner Morag McDowell found that three health professionals, who were involved with the incident, breached the Code.
Part of the Code states that people have the right to have services provided with reasonable care and skill.
McDowell also found that Te Whatu Ora Te Tai Tokerau (formerly Northland DHB) lacked policies and failed to adhere to existing procedures.
She was also critical of a lack of flexibility to enable proper staffing during a busy weekend, that had a number of high acuity patients, and of the handover process which did not consistently support the sharing of important information, such as medication allergies.
“Her death clearly had a devastating impact on her family, and I again express my condolences to them.
“I also have no doubt that staff intended to do their best for Mrs A, and that they were affected by her death and have reflected on the circumstances.”
According to the report, Te Whatu Ora Te Tai Tokerau accepted that systemic factors contributed to the error.
They said the key to preventing medication errors would be through electronic prescription, which they had been requestion for a number of years.
McDowell recommended Te Whatu Ora Te Tai Tokerau improve the process of handing over information important for safe care of patients between staff and teams.
She also said that there should be policy change to make it clear that prescribers of antibiotics must inform those taking it about the changes and ask about allergies.