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She left her husband and daughter behind.
The GP apologized to the family for the failure and has since changed the schedule of his appointments with mental health patients from 10 minutes to 30 minutes, following an investigation by the Health and Disability Commission (HDC) about the of the woman.
An HDC report, released today, found that the GP was violating the Code of Rights of Consumers of Health Services and the Disabled by giving a woman access to a potentially dangerous amount of medication.
The names and certain details of the case have not been released for privacy reasons.
Mental Health Commissioner Kevin Allan said the GP gave the woman access to an amount of medicine that could be used in dangerous ways and would increase the risk of harm to the woman.
The woman, who had a long history of substance addiction and mental illness, including suicidal ideation, was taking prescription mirtazapine and paroxetine in 2017.
The prescription stated that he must take one tablet of each medication per day, and authorized the pharmacy to dispense his fortnightly refills of 14 tablets of each medication.
A few months later, the woman moved with her family to another region where she saw a new GP and requested a refill of her prescription, which the GP granted her.
When the woman arrived at the pharmacy, she asked for a three-month supply. The request was forwarded to the GP, who, without personally checking the woman, manually changed her prescription to allow the pharmacy to dispense 90 tablets of each medication.
Allan criticized the GP’s repeated failure to document important aspects of the services he provided to the woman and said the GP did not meet professional standards.
“It was not appropriate for [the GP] to prescribe [the woman] the amount of medication she ordered without first reviewing it (or arranging for another appropriate physician to review it) and establishing that she was safe to receive it. “
Allan recommended that the GP reflect on her shortcomings and report on changes in her practice, conduct more education on the topic of safe prescribing, and apologize to the woman’s family.
It also recommended that the medical center investigate whether its GPs have been documenting their manual prescription changes adequately and consider whether more policies on manual prescription changes are necessary.
In the report, the GP said: “I am very sorry … and I accept that my documentation was substandard in this particular case and I have taken steps to ensure this does not happen again.”
He said that it was “now much more strict with the dispensing in quantity of psychotropic drugs and has[s] rejected all requests from patients who would prefer to have the full content of the script. “
He now allocates 30 minutes for all mental health patients and has stopped accepting double bookings to have more time with each patient. He also spends half an hour a day reviewing his notes.
Where to get help:
• Life line: 0800 543 354 (available 24 hours a day, 7 days a week)
• Suicide Crisis Helpline: 0508 828 865 (0508 SUPPORT) (available 24 hours a day, 7 days a week)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24 hours a day, 7 days a week)
• Whatsup: 0800 942 8787 (from 13:00 to 23:00)
• Helpline for depression: 0800 111 757 (available 24 hours a day, 7 days a week)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel that you or someone else is at risk, call 111.
