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Prescription of diclofenac to a patient who had previously experienced an adverse reaction (13HDC01041)
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(13HDC01041, 25 May
General practitioner ~ Medical centre ~ Diclofenac ~ Adverse
reaction ~ Medical history ~ Risks ~ Monitoring ~ Rights 4(1),
A man who had a complicated medical history and was taking
several medications went to a medical centre with shoulder pain and
was prescribed diclofenac (trade name Voltaren).
Several months later he was reviewed following an episode of
faintness. Blood test results showed a significant deterioration in
renal function and the GP at the time thought the diclofenac,
prescribed previously, might be causing the deterioration and he
documented this in the man's clinical notes. That GP told the man
to stop taking the medication and advised him not to take it again.
A warning was placed on the clinical file stating "Diclofenac
sodium - renal failure/retention - avoid".
The man later saw another GP for a check up. This GP recorded at
the time in the man's clinical notes "Note renal impairment with
addition of Diclofenac".
Five years later, the man saw the second GP again for ongoing
ankle pain not relieved by ibuprofen. The GP prescribed a two week
supply of diclofenac and advised the man to return in one month for
a blood test to check his renal function. The GP said that he did
not recall that the man had previously had a bad reaction to
diclofenac and did not remember any warning coming up on the
computer system about a previous reaction. Due to the merging of
the medical centre with another practice at the time and "possible
computer difficulties" in the lead up to, and during the merger,
the warning may not have featured at the time.
The man returned the following month with pain in the joints of
his right foot. The GP made a diagnosis of probable gout and
recommended that he keep taking the diclofenac. Two days later the
man returned to the GP complaining of being unable to pass urine.
The GP diagnosed urinary retention and referred him to the public
The man was assessed at the public hospital that day and was
diagnosed with acute on chronic renal failure. It became evident
that the man had had issues with 'Voltaren' and renal impairment in
the past and that he had not realised that diclofenac and Voltaren
were the same thing. The man began showing signs of multi-organ
failure and sadly passed away.
By failing to appropriately establish the man's medical history
either by adequately questioning him or reviewing his clinical
notes, by failing to take adequate regard of the man's NSAID
associated risks, particularly cardiovascular risks and interaction
with concurrent medication and by failing to adequately monitor his
renal function when prescribing diclofenac to him, the GP did not
provide services with reasonable care and skill and therefore
breached Right 4(1). The GP breached Right 6(1)(b) because the
risks of diclofenac use compared with risks or benefits of
alternative treatments were not discussed. Without this information
the man was not in a position to make an informed choice, and give
his informed consent to taking the medication. Accordingly, the GP
also breached Right 7(1).
Adverse comment was made about the medical centre for not
ensuring that its computer systems were fully functioning or that a
temporary system was in place for its doctors to follow, while the
systems were undergoing changes.