Medication Error By General Practitioner

The Mental Health Commissioner today released a report finding a general practitioner (GP) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for giving a woman access to a potentially dangerous quantity of medication.

The woman, who had a long history of substance addiction and mental illness, including suicidal ideation, was an enrolled patient with a medical centre. In 2017, her GP prescribed her mirtazapine and paroxetine. The prescription stated that she should take one tablet of each medication per day, and authorised the pharmacy to dispense her fortnightly repeats of 14 tablets of each medication.

A few months later, the woman moved with her family to another region. Three months after moving, the woman telephoned the medical centre in her former region and requested a repeat of her prescription, which the GP granted. When the woman arrived at the pharmacy, she asked to be dispensed a three-month quantity. The request was conveyed to the GP, who, without reviewing the woman personally, manually changed her prescription to allow the pharmacy to dispense 90 tablets of each medication.

Mental Health Commissioner Kevin Allan found that the GP gave the woman access to a quantity of medication that could be misused dangerously, which increased the risk of harm to the woman. He considered that the GP failed to provide services to the woman in a manner that minimised the potential harm to her.

Mr Allan also considered that the GP’s repeated failure to document important aspects of the services she provided to the woman was a clear departure from the standard described in Good Medical Practice, and that she failed to comply with professional standards.

"It was not appropriate for [the GP] to prescribe [the woman] the quantity of medication she requested without first reviewing her (or arranging for another suitable doctor to review her) and establishing that she was safe to receive it," said Mr Allan.

Mr Allan recommended that the GP reflect on her failings and report on changes to her practice, undertake further education on the subject of safe prescribing, and apologise to the woman’s family.

He also recommended that the medical centre investigate whether its GPs have been documenting their manual changes to prescriptions appropriately, and consider whether further policies concerning manual changes to prescriptions are necessary.

The full report for case 19HDC00458 is available on the HDC website.

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