Case studies: cases finalised in investigation

Investigation into a complaint in relation to the disappearance of schedule 8 medication after the death of the complainant's mother

Investigation into a complaint against Tasmanian Ambulance Service (TAS) regarding an incident at Scottsdale

Investigation into a complaint about medications prescribed by a cardiologist

 

Investigation into a complaint in relation to the disappearance of schedule 8 medication after the death of the complainant’s mother

A complaint was received from a woman in relation to her late mother’s leftover medication. Her mother had been terminally ill and had been receiving morphine for pain, including having morphine injected via a syringe driver under the supervision of Community Nursing. Her mother died at home. The complainant says that the leftover medication went missing after the mother’s death.
The complainant alleged that her mother’s carer (the complainant’s sister) and other members of her mother’s household were drug users and that this was known to the prescribing doctor.
Because of the seriousness of the matters alleged, I commenced an investigation into the matter. The focus of the investigation was: What should happen when a terminally ill patient dies and there is morphine (or any Schedule 8 medication) left over from the treatment, and this is known, or should be known, to the prescribing doctor or other medical personnel such as community nurses?
The prescribing doctor denied that he knew the carer was a drug user (although he knew she drank alcohol), and this statement was accepted. He stated that he told the carer to return any unused morphine to the pharmacy. Community Nursing stated that it was the responsibility of the family to dispose of any unused morphine.
It appeared that there are no protocols for the medical profession about disposal of leftover Schedule 8 medication in the community, and that as a result there is no evidence that the prescribing doctor did anything other than what any doctor would have done in the circumstances.
The prescribing pharmacist advised that no medication was returned to the pharmacy after the mother’s death, and that therefore the complainant’s allegation that medication had disappeared appeared to be correct.
The Pharmaceutical Services Branch of the Department of Health and Human Services supervise access to Schedule 8 medication such as morphine. They advised that the amount of unused medication was likely to have been small. Furthermore, they stated that, when the drug was legally supplied and dispensed, it belonged to the patient and thereafter to the estate. It was my view that this was an unsatisfactory state of affairs. Section 48 of the Poisons Act 1971 made it plain that schedule 8 medication could not lawfully be possessed by anyone other than the person for whom it had been prescribed, or the carer while he/she had the care of that person. Once a person dies, they can no longer possess that medication. Similarly a carer no longer has the care of a person once they are dead, and therefore can no longer legally possess that narcotic substance under the section. Once a person dies, no one can possess their leftover narcotic substances without committing an offence under section 48.
It is quite unlikely that any terminally ill person will die without at least some of their medication left over. Disposal of this medication is probably the last thing on the minds of the grieving family. In my view, the legislation needed adjusting to avoid the consequence of family members, executors or carers committing an offence.
In this particular case, the amount of leftover medication was likely to have been small. However this will not always be the case. It seemed to me that there were compelling public policy reasons why the law should prescribe what happens to this sort of medication after death.
There are many possible variables which might make it difficult for treating doctors/nurses to assume responsibility for these medications, and the recovery of Schedule 8 medication in the community might create some problems. I recommended to the Department of Health and Human Services that it seek a solution to the problem and I followed up this matter after six months to see what progress had been made in relation to achieving a solution.
DHHS advised that a national approach was being sought to drugs and poisons legislation, and that in addition a wholesale review of the Poisons Act 1971 was being undertaken. It was said that the issue would be examined in this context.

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Investigation into a complaint against Tasmanian Ambulance Service (TAS) regarding an incident at Scottsdale

The complainant initially complained to the Medical Council of Tasmania in May 2009, and the complaint was referred to this office. It involved an incident in March 2009 when the complainant’s general practitioner called an ambulance and directed it to take the complainant from Scottsdale to the Launceston General Hospital (LGH) because he suspected the complainant was suffering a heart attack (which proved to be correct). Instead the complainant was taken first to the North East Soldiers Memorial Hospital (NESMH) in Scottsdale in accordance with TAS protocol.
The complainant complained of the delay in TAS taking him to casualty at LGH. He also made a complaint against a doctor, who was on duty at NESMH. The complaint against this doctor was dismissed, because she had not directed the ambulance to go to the hospital but was merely reacting to the situation as the doctor on roster.
The complaint against TAS was retained, as it appeared to indicate possible system issues.
The complainant’s general practitioner had in the meantime complained about this matter (and a number of other incidents) to the Secretary of the Department of Health and Human Services (DHHS). This Office was subsequently informed that a Serious Incident Report was being prepared for the CEO Primary Health in DHHS.
A copy of the Serious Incident Report was provided to my Office in July 2009. The report identified that problems arose because of the structure of ambulance service in Scottsdale. Ambulance staff also worked at NESMH as either maintenance workers or nurses, and one issue identified in the report was confusion in roles and clinical responsibility, in that nursing staff were utilising their nursing competencies as opposed to providing care consistent with ambulance protocols.
It was found, however, that there had not been substantial mismanagement or inappropriate transfer in any of the cases about which the GP had complained.
One of the recommendations of the Serious Incident Report was that a TAS paramedic should be established at Scottsdale. Other recommendations dealt with improvements in documentation, improved training for ambulance staff and nurses, and encouragement for patients to dial 000 initially instead of contacting their GP.
This Office accepted the report and the recommendations; however, I decided to commence an investigation into the matter so that the implementation of the recommendations could be examined at a future point in time.
In February 2010, TAS was again contacted and asked to report on what progress had been made towards implementing the recommendations of the Serious Incident Panel. Their response indicated that high priority had been given to commencing a paramedic service at Scottsdale (which it was proposed should be established during 2010), that improved protocols were now in place in NESMH, that staff training had been implemented by TAS, and that all nursing staff’s training was now up-to-date.
It was decided at this point to close the investigation.

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Investigation into a complaint about medications prescribed by a cardiologist.

The complainant claimed that the provider cardiologist inappropriately prescribed Diltiazem to him, and that as a result he developed a third degree atrioventricular block (AVB). He claimed that this gave rise to a medical emergency while he was interstate, and to a subsequent requirement to urgently undergo the insertion of a permanent pacemaker (PPM) following his return to Tasmania. He sought an apology, disciplinary action and compensation.
The provider responded by outlining three consultations with the consumer, including the assessments, diagnosis and recommended treatment.
The consumer’s presenting symptoms were those of exertional angina, for which the provider recommended he undergo an angiogram and prescribed Diltiazem and a nitrate patch. An ECG revealed that there was also evidence at that time of asymptomatic AVB in respect of which the provider recommended the insertion of a PPM.
The consumer commenced the prescribed medications following the first consultation, including Diltiazem, but wished to speak with his GP and wife regarding the recommended angiogram and insertion of a PPM. The provider provided reasons for prescribing Diltiazem rather than other anti-anginal medication.
The provider reported an improvement in the consumer’s symptoms at the second consultation. He considered an angiogram unnecessary at that stage but considered that the insertion of a PPM should still take place. The consumer again wished to speak with his GP and wife about this. It was not until after the third consultation that the consumer agreed to have the PPM inserted.
The procedure was booked for some three weeks hence, and in the meantime the consumer travelled interstate to visit family.
While he was interstate, the consumer experienced a pre-syncopal episode and chest pain and was admitted to hospital, where he was diagnosed as suffering from AVB. The provider expressed the view that the extent of the AVB experienced by the consumer while interstate was no worse than the AVB being experience by him when reviewed previously, and as such he did not consider that it was a case of the Diltiazem having a deleterious effect, and more likely an episode of exertional angina.
The medical information service MIMS reports Diltiazem to be contraindicated when there is second/third degree heart block and no PPM. The complaint was referred to investigation to ascertain whether Diltiazem should properly have been prescribed in this case.
An expert opinion was obtained from an interstate cardiologist, who in the most part agreed with the provider.
In summary, I concluded that the provider’s prescription of Diltiazem was not inappropriate and did not demonstrate a lack of due skill.
I also identified that this was a complaint that would have benefited from referral to conciliation as opposed to investigation.

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