Health and Disability Commissioner report finds inadequate ophthalmology care
The Health and Disability Commissioner (HDC) has found two ophthalmology doctors and a District Health Board (DHB) breached the Code of Health and Disability Services Consumers’ Rights (the Code) in relation to the care provided to an eye surgery patient, Ms A.
In August 2013, Ms A underwent eye surgery. The procedure was performed by a senior ophthalmology trainee Dr B, under the supervision of Dr C. During the operation, Dr B inadvertently touched Ms A’s fovea with a surgical instrument. The eye’s fovea is responsible for sharp central vision and in this case Dr B’s actions caused irreversible damage to Ms A’s eyesight.
Ms A complained to the HDC and alleged that she did not consent to Dr B acting as the operating surgeon, that both doctors failed to administer the requisite standard of care during surgery, and did not disclose sufficient information after the surgery.
The HDC recommended that Dr B and Dr C provide a written apology to Ms A and attend various training courses. The HDC also recommended that the DHB review its ‘Agreement to Treatment’ form, provide additional training for ophthalmology staff, and audit patient records in the ophthalmology department.
Pharmacist risks disciplinary proceedings for dispensing error
A pharmacist may face disciplinary action after another HDC report which found he had breached the Code in making and failing to disclose a dispensing error.
In October 2013, Mr A sought to collect a renewed prescription for his regular medication, cyclosporine (white tablets designed to treat patients following an organ transplant). A technician at the pharmacy, Mr E, erroneously gave Mr A cyclophosphamide, a chemotherapy drug which comes in the form of pink tablets. This dispatch was later signed off by a pharmacist, Mr C.
Mr C discovered the dispensing error when Mr A enquired about the difference in appearance between the cyclophosphamide tablets and his regular cyclosporine prescription. Mr C did not inform Mr A of the incident, complete an incident report, or inform other staff at the pharmacy. Rather, Mr C told Mr A that the medication was a ‘discontinued product’.
The HDC recommended that Mr C provide a written apology to Mr A. Mr C’s case was referred to the Director of Proceedings, who will now determine whether proceedings should be brought against Mr C.
Changes to Midwife’s register to take place
The Midwifery Council of New Zealand (the Council) publishes an online register of midwives in New Zealand. The register contains a range of information including the name of the midwife, the town in which they practice, whether they have a current practising certificate, and whether there are any conditions on their practice.
The register is designed to help expectant parents choose a midwife. In March 2015, the Council agreed to amend the register to include all names that a midwife had practised under.
This change was triggered by a Blenheim midwife who was found to have provided sub-optimal treatment by the Human Rights Review Tribunal in February 2015. When treating a 16 year old patient, the midwife failed to provide services with reasonable care and skill, failed to comply with relevant legal and professional standards, and omitted to provide services in a manner that minimised risk to her patient. On one occasion, the midwife advised the patient that she could reduce the pain from a perineal tear by being ‘ladylike’ and keeping her legs together.
The midwife is now practising in Northland under a different surname. However, the midwives’ name (as recorded in the Human Rights Review Tribunal decision) does not appear in the register.
In March 2015, in an effort to improve transparency, the Council agreed to amend the register to include all possible variations of a midwife’s name. The register has not yet been amended. In response to criticisms regarding the delay, the Council said it had limited staff and the change to the register is due to be implemented at the end of September 2015.