Management Of A Prisoner's Medication

Deputy Health and Disability Commissioner Kevin Allan today released a report finding the Department of Corrections (Corrections), Clendon Pharmacy and a doctor in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failing to manage a man’s medication correctly.

The man was prescribed long-term clopidogrel (an antiplatelet medication used to reduce the risk of heart disease and stroke) after he had been hospitalised following a stroke. He received the medication for only a month before it was stopped in error. It was not until the man was re-admitted to hospital several months later, after suffering a heart attack and having four stents placed in his heart, that he began receiving the clopidogrel again. However, after two months the clopidogrel was again stopped incorrectly. It was not until several months later, after the man had been hospitalised a further three times, that he began receiving clopidogrel again.

Mr Allan considered there where a number of failings by Corrections staff that represented a pattern of poor compliance with Corrections’ policy and a concerning lack of critical thinking, and contributed to the man not receiving his medication as intended.

The Deputy Commissioner noted that in addition to the responsibilities under the Code, under the Corrections Act Corrections is required to provide prisoners with a "standard of health care that is available to prisoners in a prison must be reasonably equivalent to the standard of health care available to the public". Mr Allan further highlighted that prisoners do not have the same choices or ability to access health services as person living in the community. They do not have direct access to medication or to a GP. They are entirely reliant on the staff at Corrections’ health services to assess, evaluate, monitor, and treat them appropriately.

Mr Allan recommended that Corrections provide a written apology to the man, which it has done. Other recommendations included arranging for an independent external review of the level of GP cover provided at Auckland Prison, reporting to HDC on its new process for medication self-administration signing sheets, reviewing a sample of recent discharges from hospital to Auckland Prison to ensure that appropriate care plans are in place, and reporting to HDC on the medical officers’ review of medication charts.

The case has been referred to the Director of Proceedings to decide whether any legal proceedings should be taken against Corrections.

Mr Allan also identified a number of deficiencies in the care to the man that Clendon Pharmacy provided to the man including dispensing the medication without a current medication chart, discontinuing the medication when it was charted to continue and not having internal procedures in place for processing orders from Corrections.

The Deputy Commissioner recommended that Clendon Pharmacy provide an apology to the man, which it has done. Other recommendations included undertaking a random audit of dispensing to the prison health centre, develop an anonymised case study based on HDC’s report as the basis for training staff and sharing this study with the Health Quality and Safety Commission.

Corrections and Clendon Pharmacy were also recommended to meet to discuss HDC’s report and any further issues identified, and report back to HDC.

Mr Allan was also critical of the doctor incorrectly transcribing the hospital prescriptions which contributed to the man not receiving clopidogrel for as long as was intended.

The full report for case 17HDC01348 is available on the HDC website.

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