Monday, July 09, 2007

Coroner criticises hospital

Friday, 6 July 2007 

Coroner criticises hospital

The doctor of a Christchurch woman who died from complications with her psychiatric medication was not told of the dangers of the drug when she was being treated by Hillmorton Hospital.

In the Coroner's Court in Christchurch yesterday, a professor of general practice labelled the error "appalling" and a "dereliction of duty".

Karen Cramp, 47, died in 2004 after the antipsychotic drug clozapine lowered her natural immunity.

She then contracted an infection that she was unable to fight off.

There were delays in admitting Cramp to hospital.

She appeared to her doctor, Mark Henley, to merely have flu symptoms.

As clozapine is a specialist-only prescription drug, Henley, a GP, was not aware of the extra vigilance needed when a patient on the drug presented with an infection.

Otago Medical School professor of general practice Murray Tilyard yesterday told the coroner that Hillmorton Hospital should have told Henley about the dangers of clozapine when Cramp was put on the drug.

Tilyard said it was "immaterial" whether the producer of the drug, Novartis, had information directly available to GPs.

Cramp's discharge letter from Hillmorton had "no indication of what Henley should be looking for", he said. "I view it as a dereliction of duty. There's nothing in the Privacy Act that stops health professionals from exchanging appropriate information about a patient," he said.

"It is the duty of care by any initiating prescriber to give information to any subsequent health professional."

Hillmorton's actions were "grossly deficient", he said.

Cramp's stepdaughter, Colleen Herriott, agreed Hillmorton's actions were inadequate.

"They tell people to go to GPs but they're under-resourced."

Herriott said she thought GPs had an ethical obligation to investigate medications their patients were on if they did not know what complications could entail. "To just say `I didn't know' is a bit of a cop-out."

Tilyard praised Henley for having the foresight to make a possible link between Cramp's condition and her medicine, and order a blood test.

The blood sample was clotted and unusable and though a re-test was ordered, her symptoms did not appear to require urgency.

A routine blood test a few days later showed Cramp had a dangerously low white blood cell count and she was admitted to hospital. She died about a week later on October 14.

Henley, testifying via telephone from Queenstown, said it would have been "helpful" if GPs had details of the risks of clozapine.

Psychiatrist Mark Earthrowl said the death had triggered a "serious event review" that had identified a "multi-systemic failure" to identify the importance of the blood test.

The report had recommended GPs be given information packs about the risks of clozapine.

A Canterbury District Health Board (CDHB) spokeswoman yesterday said: "The CDHB is surprised by the professor's comments that were not part of his expert report to the coroner.

"It will be awaiting the coroner's decision, based on all of the evidence, before making any further comment."

Coroner Trevor Savage adjourned the inquest to draft his findings.


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