Names have been removed (except the expert who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint from the complainant about the standard of service provided by the general practitioner to the consumer while a resident at the rest home. The complaint is that:
- The doctor's surgery did not inform the complainant that the consumer had a urinary tract infection.
- On receiving the results of the urine specimen, the manner in which antibiotics were prescribed has to be questioned.
- The general practitioner failed to visit the consumer when requested and did not follow up the prescribing of antibiotics.
The complaint was received on 25 June 1997 and an investigation commenced into both the general practitioner and the complainant's involvement in the treatment the consumer received while she was a resident at the rest home. Information was obtained from the following:
The General Practitioner
The Complainant The Rest Home Nurse Manager
The Consumer's daughter
Copies of clinical notes held by the general practitioner and records held by the rest home were copied and considered.
Information Gathered During Investigation
In early May 1997 the consumer was admitted to a rest home for respite care while her family went to England on holiday. The consumer was in frail health and could not be left alone. Her medical problems included advanced Waldenstrom's macroglobulinaemia (a condition where excessive amounts of a protein that functions as an anti-body in the blood is present because of a proliferation of white blood cells) complicated with bone marrow failure and peripheral neuropathy - a condition requiring recurrent blood transfusions, partial sight, osteoarthritis, and anorexia. The general practitioner, who does not have regular patients at the rest home, was the consumer's general practitioner.
The consumer's daughter informed staff that the consumer was completely blind in her right eye, had recently undergone surgery and was due for further treatment. Staff were not aware of any other complications of her medical history. During the investigation the complainant advised the Commissioner that long stay residents usually arrive with full medical notes. However, the rest home is often not informed of the medical background of short stay residents.
In early May 1997, staff noticed that the consumer was incontinent of urine. Two days later the consumer's urine smelt offensive and she told staff she occasionally had cystitis. The complainant contacted the general practitioner's surgery and spoke with a practice nurse requesting a form to send a urine sample to the laboratory. A urine specimen was organised for the laboratory that day. A mid-stream specimen of urine result is returned in 24 hours if there is no infection and in 48 hours if there is. The complainant expected the result back within three days at the latest.
When the complainant had not heard anything four days after the test was taken, she contacted the general practitioner's surgery and spoke with the practice nurse who informed her that the results showed a growth of bacteria. The complainant then asked to speak to the general practitioner about a prescription for antibiotics but was informed this was not necessary and that the nurse would check on the computer as to what antibiotic the consumer was on last time. The nurse went on to prescribe ceclor 250mg, one a day for seven days. The complainant questioned this dose and again asked to speak to the general practitioner. The nurse rechecked the dose and informed the complainant that the dose was ceclor 250mg, one to be taken three times a day for seven days. The complainant asked to have this confirmed by the general practitioner and was reassured by the nurse that the general practitioner checked all prescriptions put through. The complainant rang the pharmacist who dispensed the antibiotics from verbal instruction. The consumer commenced that day on the antibiotics.
The general practitioner explained during the investigation that the prescribing procedure is that the nurse generates the prescription form which the doctor then signs. This is then picked up or faxed to the pharmacist. The general practitioner can not say what happened in this case but can vaguely remember signing the script. No nurse in the practice prescribes or dispenses, though they may advise the caller about urinary tract infections and ask if there is an allergy. The general practitioner has not provided confirmation that she signed the prescription.
On the following day the complainant contacted the general practitioner's surgery, requesting that she visit the consumer at the rest home. The general practitioner informed the Commissioner that this message did not get through to her and explained there are three registered nurses working for several doctors in the practice. Doctors expect to be informed of messages requesting a home visit and a message is left on the doctor's door. In this instance the procedure was not followed because there was a new nurse on at the time, who left the message in the repeat prescription book in error. The general practitioner said she has established clearly with the practice nurse a definite route of communication to prevent such instances recurring.
A further call was made by the complainant to the general practitioner's surgery on the next day but the general practitioner had gone on holiday. The practice nurse left a message on the general practitioner's mobile phone message service.
The consumer had a fall the following day. The registered nurse on duty at the time phoned the surgery. The general practitioner was unavailable and the emergency doctor on call attended to the consumer who was hospitalised.
On the day the consumer fell the general practitioner cleared her telephone messages from the previous day, telephoned the rest home and spoke to a staff member who advised her of the consumer's fall and hospitalisation. The general practitioner then rang the practice nurse, who had left the message at home, to point out to her that the communication had been inadequate. The general practitioner said she asked the practice nurse to make the other nurses aware that the communication had been inadequate and that they must get hold of a doctor in person if a house call is to be made. When the general practitioner returned from holiday she rang the complainant.
The consumer did not recover and in early June 1997 the complainant was notified by the consumer's son that the consumer had passed away.
The Code of Health and Disability Services Consumers' Rights
The following rights are applicable to this complaint:
Right to Services of an Appropriate Standard
2)Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards
5)Every consumer has the right to co-operation among providers to ensure quality and continuity of services.
Right to be Fully Informed
1) Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive, including -
f) The results of tests;
Opinion: Breach - the General Practitioner
In my opinion the general practitioner has breached Right 4(2), Right 4(5) and Right 6(1)(f) of the Code of Health and Disability Services Consumers' Rights.
Rule 3 of the New Zealand Medical Association's Code of Ethics states that doctors should:
"Ensure that every patient receives a complete and thorough examination…".
While a prescription for antibiotics was eventually given, this was only after the complainant contacted the general practitioner's surgery when she had not heard any further about the lab results. The general practitioner left for her holiday without following up on the condition of her patient. In my opinion the general practitioner should have followed up the prescription with at least a telephone call to the home before she went away on holiday. The general practitioner did not examine her patient, she prescribed medication and made no attempt to follow this up. In my opinion the general practitioner's actions were not reasonable in the circumstances and she did not provide the consumer with an appropriate standard of service.
The general practitioner did not provide the consumer with services that ensured cooperation between her and staff at the rest home.
The consumer was admitted to the rest home for respite care, with staff at the rest home unaware of the full extent of her medical condition. With the consumer's primary caregiver away overseas, staff at the rest home relied on the consumer's general practitioner to be familiar with her medical history and keep them informed of any necessary treatment interventions.
When staff became concerned about the consumer's condition they made repeated calls to the surgery but were unable to speak to the general practitioner. The general practitioner acknowledges that there was a communication breakdown resulting in the home visit request not reaching her. The systems that were in place were inadequate and broke down, resulting in a service which was not effective in ensuring quality and continuity between providers.
Despite signs of a urinary tract infection, no attempt was made to contact the rest home to inform staff of the test results and the appropriate course of treatment. Only after the general practitioner's staff were prompted with a telephone call from the rest home's staff were the test results confirming an infection conveyed. Providers have an obligation to inform consumers of the results of tests. The onus is not on the consumer to have to insist on this information. The general practitioner did not meet this obligation and has, in my opinion, breached Right 6(1)(f) of the Code of Rights.
A review of communication procedures between nursing staff and doctors, as well as procedures for practice nurses' telephone communications with patients, was completed on 18 June 1997.
Future Actions: the General Practitioner
I recommend that the general practitioner undertake the following actions:
- Apologise in writing to the family of the consumer for failing to provide the consumer with appropriate services during her stay at the rest home. This apology is to be sent to the Commissioner and will in turn be forwarded to the consumer's family.
- Apologise in writing to the complainant for not ensuring the rest home's staff had sufficient information to provide the consumer with quality services. This apology is to be sent to the Commissioner which in turn will be forwarded to the complainant.
- Review procedures in relation to communicating lab results to ensure that all relevant parties are kept informed. A copy of the policy and procedures in place is to be sent to the Commissioner on completion of the review.
- Ensure communication procedures are included in the orientation of new, casual and temporary staff employed by the practice.
In addition, a copy of this opinion will be sent to the consumer's daughter, and the president of the New Zealand Medical Council.
Opinion: No Breach - the Complainant
In my opinion the actions taken by the complainant were appropriate and did not result in a breach of the Code of Rights.
Future Actions: the Rest Home
I recommend that any patients arriving for respite care should provide relevant medical information to ensure adequate care is able to be provided.