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HEALTH AND DISABILITY COMMISSIONER FINDS BREACHES OF CODE IN RELATION TO CHILDREN
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In two recent Health and Disability Commissioner decisions, the HDC has found an orthodontist and two nurses in breach of the Code of Health and Disability Services Consumers’ Rights in respect of healthcare services provided to children.

Orthodontist in breach of Code for removing child’s teeth without consent

The HDC has found that an orthodontist breached the rights in the Code when he removed three teeth from an 11 year old girl’s mouth without informing her or obtaining consent. The girl was said to be left “traumatised” following the incident.

In April 2014 Miss A went to see Dr B to determine if orthodontic treatment would be necessary in the future. During the course of the appointment, Dr B removed two of Miss A’s baby teeth prior to her or her mother becoming aware of the situation. When Miss A’s mother questioned Dr B about what he was doing, she said he replied ‘I needed to get them out, because food could get stuck under them’. Dr B then proceeded to remove a third baby tooth from Miss A’s mouth.

Dr B told the HDC that he made a clinical decision that it was in Miss A's best interest for the teeth to be removed. He acknowledged that removing teeth from children is a sensitive matter, and stated that he always intends extractions to be performed in a way that causes the least stress and discomfort to a child.

Dr B later said he was aware he had made a decision that was not his to make, and that he should have discussed the required treatment more fully with Miss A’s mother prior to removing the baby teeth.

Miss A’s mother also alleged that Dr B’s assistant physically restrained Miss A, and made insensitive comments about Miss A’s reaction to the procedure. Miss A’s mother made a complaint to the HDC.

HDC findings

The HDC found that Dr B had breached Right 6(1)(b) and Right (7)(1) of the Code. These Rights require that consumers are provided with reasonable information, including an explanation of the options available, so that the consumer can make an informed choice about their treatment. The Dental Council of New Zealand Code of Practice also states that a consumer must be given information on proposed treatments, and must agree to the treatment before it is commenced.

The HDC found that all parties understood the purpose of the appointment was a discussion of future orthodontic treatment. During the appointment, Dr B made a ‘judgment call’ to remove three of Miss A’s teeth without informing Miss A or her mother that the teeth required removal, nor providing information of the options available for removal such as anaesthetic or a referral. The HDC was concerned that Dr B let his personal views dictate the course of treatment without having any regard to the wishes of Miss A or her mother. This amounted to a breach of the Code. Dr B also breached Right 4(2) of the Code by failing to document the removal of the teeth in Miss A’s clinical records.

In relation to the complaint that Miss A was inappropriately treated, Dr B and his assistant said that comments were made in a light and humorous fashion to ‘minimise any discomfort or distress’. Both denied allegations that Dr B’s assistant physically restrained Miss A in the chair, and said that she was guided gently back into the seat.

On the basis of these conflicting accounts, the HDC was unable to conclude whether or not the staff had behaved inappropriately towards Miss A. The HDC reiterated the importance of consumers and their families being treated with professionalism and courtesy at all times during medical treatment.

The HDC required Dr B to write a written apology to Miss A and her mother, and recommended that the Dental Council of New Zealand review Dr B’s competence. The Clinic was required to fund an education seminar for its staff on informed consent.

Three year old boy given 10 times the intended dose of codeine

The HDC also recently considered a claim from the parents of a three year old boy who was accidently given a codeine overdose 10 times greater than his intended dose, which was almost twice the recommended dose of a grown adult. Both the nurse that administered the dose and a senior nurse that checked the dosage were found to have breached Right 4(1) of the Code.

In January 2013 three year old Master A and his four year old sister were in a hospital room being prepped by a nurse to have their tonsils and adenoids removed. At around 8am anaesthetist Dr B conducted a review of the children and explained to them and their mother how anaesthesia would be induced during the surgery.

Dr B then prescribed paracetamol and codeine as pre-medications. For children, dosages for both medications are calculated and prescribed according to the child’s weight in kilograms, with the recommended dose of codeine being 0.5mg per kg of bodyweight. Dr B told the HDC that she calculated the dosages aloud, then charted 8.5mg of codeine for Master A, who weighed 17.1kg, and 8mg of codeine for his slightly smaller sister. Dr B then asked the nurse to prepare the pre-medications for Master A.

The nurse had 6 years’ experience as a registered nurse. She had commenced employment at the hospital four weeks earlier, and was working her first shift alone following an introductory ‘buddy period’. The nurse advised the HDC that she had minimal paediatric experience, and had not received any orientation training in paediatrics from the hospital.

After receiving the prescriptions from Dr B, the nurse found a senior nurse to check the medications and draw up the dosages with her. Both nurses independently read Master A’s prescription for codeine as ‘85mg’, rather than ‘8.5mg’. They both allege that there was no clearly written decimal point on the form.

The nurse later told the HDC she was aware that the usual adult codeine dosage ranged between 30-60mg, however she said that she trusted her ‘more experienced checker for this pre-med dosage’. The senior nurse commented that the dosage of codeine was more than the usual for a child, and asked the nurse whether Master A was a ‘big boy’. Although the nurse confirmed he was not, the senior nurse told the HDC that she considered Master A might have ‘some absorption problems’ that required a higher than normal dose of codeine.

The nurse administered 85mg of codeine to Master A orally with a syringe. The boy’s mother told the HDC that she commented that the syringe was awfully large, but the nurse assured her it was correct.

The nurse then went to prepare the medications for Master A’s sister and noticed the prescribed amount of codeine was 8mg. She immediately became concerned and went to check the situation with Dr B. It became apparent that an overdose had been administered to Master A.

Dr B consulted with Master A’s surgeon, and it was agreed that they would pump his stomach and then proceed with the planned surgery. According to Dr B and the surgeon the operation was successful and Master A showed no evidence of codeine overdose.

After the error was realised a clear decimal point was visible on the prescription form. Both nurses deny that this point was present when they reviewed the form. Dr B denies altering the form to make the decimal point more pronounced. When the HDC asked the New Zealand Police Document Examination Service to analyse the medical chart, it found that that the 8.5mg entry was completed in a liquid ink, while the remainder of the entry was completed in a black ballpoint pen ink. All other parties with access to the medication chart denied altering the chart.

HDC findings

The HDC found that the nurse demonstrated ‘very poor judgment’ when she administered 85mg of codeine to Master A. She failed to provide Master A with services with reasonable care and skill in breach of Right 4(1) of the Code.

Although the HDC acknowledged that the nurse was working her first shift alone, it did not consider her lack of experience a significant mitigating factor in this case. Registered nurses are expected to have the generic knowledge, skills and ability to work across all patient groups. Codeine is a commonly prescribed analgesia, and the nurse was aware that the usual adult dose is 30-60mg. She administered more than the recommended adult dose to three year old Master A. The HDC considered this to be unacceptable.

The HDC also found that the senior nurse breached Right 4(1) of the Code. The HDC was particularly troubled by her actions, stating it was her role to act as an independent check for her junior colleague and act as ‘safeguard’ against prescription errors. Instead she allowed the incorrect dosage to be administered to Master A.

In relation to the legibility of the prescription form, the HDC considered Dr B’s documentation suboptimal but not a breach of the Code. The HDC declined to make a finding on who had altered the prescription form as there was insufficient evidence to draw a conclusion.

The HDC recommended that both nurses and the hospital provide a written apology to Master A and his family for breaches of the Code and deficiencies in care provided. The HDC also recommended that the Nursing Council of New Zealand consider whether a review of either nurse’s competence is warranted. It was recommended that the hospital consider amending its Medication Management Policy, and provide a report and training on the topic of medication administration incidents to staff.

This article was authored by Helen Brown, a Senior Associate, and Alexandra Kissling, a Law Graduate, in our Wellington office.

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