Director of Proceedings v Chief Executive, Department of Corrections  NZHRRT 33 (20 July 2021)
The Director filed proceedings by consent against the Chief Executive of the Department of Corrections (“the defendant”) in the Human Rights Review Tribunal, regarding the care it provided to Mr A, a person in prison.
The defendant exercises statutory functions conferred under the Corrections Act 2004. Under section 75 of the Corrections Act 2004, the defendant is required to provide people in prison with “medical treatment that is reasonably necessary”, and the “standard of health care that is available to prisoners in a prison must be reasonably equivalent to the standard of health care available to the public”. Every prison has a health service that employs and contracts health practitioners to provide health and disability services to people in prison.
Mr A, a person in prison, was hospitalised following a stroke and a heart attack. On discharge, the hospital prescribed him long-term clopidogrel. At the time of these events, long-term clopidogrel was accepted first-line 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 general practitioner (“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). At some stage after this, 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 and had four stents inserted in his heart. It was discovered at this time that Mr A’s clopidogrel had been stopped in error and 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.
During the relevant period, the pharmacy with which the defendant contracted to provide pharmacy services to the prison, had been either dispensing or discontinuing Mr A’s clopidogrel in response to confusing and conflicting communications and documentation from prison health staff about Mr A’s medications. Prison GPs had been generating prescriptions of clopidogrel but the medication order forms provided to the pharmacy were not reflecting this (with some nurses discontinuing the medicine on the order form in reflection of the confusing medication chart, and other nurses requesting it be dispensed).
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 care provided to Mr A fell well below the accepted standards.
In particular, the defendant accepted that the failures in delivery of health care included:
- Failure to develop a care plan for Mr A after any of his public hospital admissions, contrary to the defendant’s policies and legal requirements.
- Contrary to the defendant’s policies and legal requirements, Mr A’s medication chart was ambiguous and at times illegible and difficult to follow, and prison staff failed to present his chart to the prison GPs for replacement.
- The signing sheets for Mr A’s medications did not record whether Mr A was given medication to self-administer, and there were gaps in the dates covered.
- Failure to educate Mr A about his own health such that he could have recognised the significance of the missing clopidogrel and reported it to health staff.
- There was a poor standard of communication with the pharmacy in respect of Mr A’s medications.
- There were inadequacies in the care provided to Mr A by a number of contracted GPs, for which ultimately the defendant was responsible. In particular:
- There were missed opportunities for the GPs to identify that Mr A had not been receiving clopidogrel.
- The GPs failed to address the risk of misinterpretation of Mr A’s medication needs, by completing a replacement medication chart.
As a result of these failures, Mr A did not receive the medication he needed to lower the risk of a heart attack or stroke and to help prevent his stents from becoming blocked, and Mr A was exposed to a risk of harm unnecessarily.
The defendant accepted that its failures in care amounted to breaches of the Code of Health and Disability Services Consumers’ Rights (“the Code”), and the matter proceeded by way of an agreed summary of facts. The Tribunal was satisfied that the defendant failed in the care it provided to Mr A, and issued a declaration that the defendant 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 at:
 An anti-platelet medication or blood thinner used to prevent the formation of blood clots as a measure to reduce the risk of heart disease and stroke.
 Ischaemic heart disease is a condition where a waxy substance called plaque builds up inside blood vessels and restricts the normal flow of blood.