Mr A, a person in prison, was hospitalised following a stroke and a heart attack. On discharge, the hospital prescribed him long-term clopidogrel (an antiplatelet medication or blood thinner). At the time of events, long-term clopidogrel was accepted firstline treatment for secondary prevention of stroke. If a patient stops taking clopidogrel or does not take it at all, there is an increased risk of serious heart conditions, stroke, or a blood clot in the legs or lungs. These conditions can be fatal.
After Mr A’s hospital discharge, a GP at the prison transcribed Mr A’s clopidogrel prescription for only one month in error, and entered it on Mr A’s medication chart in the “short course medication” section (as opposed to the “regular medication” section). Some time later, a member of the prison health staff struck out clopidogrel on Mr A’s medication chart, and then attempted to reinstate it by writing: “ERROR, crossed out by mistake.” Three months later, Mr A was hospitalised with ischaemic heart disease (where plaque builds up inside blood vessels) and had four stents inserted in his heart. Only then was it was discovered that Mr A’s clopidogrel had been stopped in error and that he had not been receiving it. Mr A started receiving long-term clopidogrel again. However, two months after his second hospital discharge, the clopidogrel was again stopped incorrectly. It was not until three months later, and after three further hospitalisations with a finding of significant coronary artery disease, that Mr A began receiving clopidogrel again.
The defendant accepted that cessation of Mr A’s clopidogrel was a serious oversight that was perpetuated even after being picked up by the public hospital and despite many opportunities to identify and rectify the error. The defendant accepted that there were a number of failures by several prison health staff responsible for Mr A’s care, indicating broader systemic issues for which, ultimately, the defendant was responsible. The defendant accepted that communication and documentation were seriously inadequate, and there were poor processes, a concerning lack of critical thinking, and poor compliance with policy by multiple providers, which contributed to Mr A not receiving his clopidogrel medication as intended. The defendant agreed that the care provided to Mr A fell well below the accepted standards.
The defendant accepted that its failures in care amounted to breaches of the Code, and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that the defendant had failed in the care it provided to Mr A, and issued a declaration that the defendant had breached Right 4(1) of the Code.
The decision is an important reminder that people in prison make up a unique and particularly vulnerable group. People in prison do not have the same choices or ability to access health services as a person living in the community, and do not have direct access to medication or to a GP. They are entirely reliant on prison health staff to assess, evaluate, monitor, and treat them appropriately. The Tribunal’s decision can be found on the Ministry of Justice website: www.justice.govt.nz