Appropriate Standard Of Care Not Provided By Rheumatology Clinic And Consultant Physician

The Deputy Health and Disability Commissioner has found a DHB (now Health New Zealand | Te Whatu Ora) breached the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to provide a reasonable standard of care to a woman at a rheumatology clinic.

Deborah James also found a consultant physician breached the Code for not providing an appropriate standard of care in his overall management of the woman’s symptoms with prednisone, and his lack of consideration of non-inflammatory pathologies as a potential cause of her pain.

The woman had rheumatoid arthritis (RA) and was prescribed prednisone as part of her treatment. The clinic shared responsibility for prescribing prednisone with the woman’s GP. The woman developed unresolved ankle pain, and a second opinion was sought from a different physician at the clinic. The second physician diagnosed the women with a non-union fracture [1] in the right ankle.

Ms James found that the physician could have sought a second opinion from another rheumatologist and an x-ray of the woman’s right ankle at an earlier date. Ms James was also critical of the physician’s lack of documentation of monitoring tests in light of the risks of prednisone use.

Ms James found the rheumatology clinic breached the Code for failing to provide an appropriate standard of care | taukitanga. She expressed concern about the level of service provision and noted that, due to workload pressures, the woman was often seen by the clinical nurse specialist (CNS) rather than the consultant physician or a specialist doctor.

"I consider the pressures created by insufficient resourcing of the rheumatology service directly contributed to an environment in which the CNS was able to provide advice on prednisone dosages when not authorised to do so, and that this was not seen as an issue by the consultant physician."

Ms James made several adverse comments in her report including for coordination of care between the medical centre and rheumatology clinic in monitoring the diabetes risk and the prescribing of prednisone.

She also made an adverse comment about the CNS for providing advice on dosages when she was not authorised to do so, however, Ms James noted this was mitigated by the pressures created by insufficient resourcing of the rheumatology service.

Since the events, Health New Zealand and the consultant physician have made changes, outlined in the report. Ms James acknowledged that after these events, the DHB received additional funding which has been used for locum cover and increased additional nurse specialist hours.

[1] Non-healing broken bone

The full report of this case can be viewed on HDC’s website - see HDC's ' Latest Decisions'.

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