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Administration and documentation of medication to prison inmate (13HDC00853)

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(13HDC00853, 26 June 2015)

Prison health care ~ Registered nurse ~ Doctor ~ Dental procedure ~ Pain management ~ Administration ~ Documentation ~ Right 4(1)

A 30-year-old man was an inmate at a correctional facility. The man had a dental procedure, following which he continued to bleed from the wound, was vomiting, and experiencing hot and cold flushes.

Over the following 50 days, the man continued to experience pain resulting from the procedure and submitted written requests for clinical review or pain relief on five occasions. The man also recalls making verbal requests to facility staff on a number of occasions for medical review, pain relief, or for antibiotics to be supplied.

On the day following the procedure, the man was prescribed Pamol twice daily as required, however there are no records of the administration of Pamol. The man was then prescribed Pamol three times daily for eight days following the procedure, however it is recorded that he received Pamol four times in total.

Following the procedure, the man was prescribed Brufen twice daily as required, however it is recorded that he received Brufen three times in total. The man was then prescribed Brufen three times daily over eight days, however it is recorded that he received Brufen 25 times in total. During this time, the man received Brufen five times a day on two consecutive days and, over the next six days, it is recorded that the man received Brufen on ten occasions in total. However, there is no record of why he received Brufen on these occasions.

Following the procedure, the man was prescribed Augmentin three times daily for nine days. He should have received 27 doses, however it is recorded that he was administered Augmentin on 12 occasions in total. It is recorded on only one day that he was administered Augmentin three times as prescribed.

Following the procedure, the man was prescribed metronidazole three times daily for eight days. He should have received 24 doses, however it is recorded that he was administered metronidazole on eleven occasions in total. It is recorded on only one day that he was administered metronidazole three times as prescribed. 

For a period of 26 days, the man was prescribed naproxen and Voltaren for pain. There is no record that either naproxen or Voltaren were administered to the man on any occasion.

It was held that facility staff consistently failed to provide the man with medication in accordance with his prescription, and repeatedly failed to assess him prior to administration of medication. There was a pattern of suboptimal clinical documentation by multiple staff involved in the man's care, which indicated a lax attitude towards documentation within the facility. The facility failed to ensure that the man was provided services with reasonable care and skill and breached Right 4(1).

The Department of Corrections was referred to the Director of Proceedings.The Director of Proceedings filed proceedings by consent against the Department of Corrections in the Human Rights Review Tribunal. The proceedings were resolved by negotiated agreement which included the Tribunal issuing a declaration that the Department breached Right 4(1) by failing to provide health services with reasonable care and skill.

Adverse comment was made about the facility for placing the man on a soft diet for three days without any plan to review him before placing him back on a regular diet. Adverse comment was also made about a doctor for documentation errors relating to prescribing. 

 

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