Prescription confusion may have contributed to woman's death
Photo:
David GABIS / 123RF
A coroner says Health New Zealand should centralise medicine dispensing records after he found a mistake with a morphine prescription may have contributed to a Levin woman's death.
Coroner Mark Wilton found 71-year-old Norma Collins' death, at her home in May 2022, was associated with chronic obstructive pulmonary disease (COPD), with a background of excessive morphine administration.
He could not determine the exact cause of Collins' death because she was cremated before it was reported to the coroner, and no post-mortem or toxicological analysis was done.
But he found a GP at Ōtaki Medical Centre inadvertently prescribed a higher strength and dosage for Collins, which the pharmacist did not know about - and could not alert crucial people to.
Collins suffered from end stage COPD with type 2 respiratory failure, pulmonary hypertension and anxiety.
In the lead-up to her death she was prescribed morphine at 1mg strength at a dose of 2.5 to 5ml every three hours as needed by doctors at the Arohanui Hospice.
Her daughter, who was Collins' carer, administered the morphine. She was advised to contact Ōtaki Medical Centre for repeat prescriptions. She did this in late May, concerned the liquid morphine was running out.
A GP at the practice - who was not Collins' usual doctor, nor the lead practitioner at the centre - prescribed a higher dosage of 50ml of liquid morphine, at a higher strength of 10mg, administered at 1mg amounts.
The GP told the Health and Disability Commissioner he checked prescribing records and the Ministry of Health database for Collins' medication history, but could find no previous prescription for liquid morphine, only one for a slow-release 10mg morphine tablet.
He said he had not had specific palliative care training.
"He said that he was unaware that Collins had previously been prescribed liquid morphine of a different dose and concentration by a doctor at Arohanui Hospice," Wiltobn said.
The prescription was sent to Berrys Tararua Pharmacy, which had not dispensed the first prescription for Collins. It did not have access to her dispensing records so did not advise her daughter of any change.
Wilton's report found Collins' daughter administered the drug as she had been doing - noticing her mother was drowsy and sleeping for hours at a time.
"Collins' daughter did not think this was unusual as her mother had slept for long periods of time previously."
She was found dead in her bed the morning of 31 May.
Wilton said Health NZ should centralise dispensing records and share dispensing information through the New Zealand Electronic Prescription Service, following a previous finding by Coroner Alexandra Cunninghame.
The service allows communication between prescribers and pharmacists, including emailing prescriptions and notifications for medications that have not been dispensed.
He said if Berrys Tararua Pharmacy had access to dispensing records, the pharmacist could have checked out the different prescription.
"This would have allowed the pharmacist at [Berrys Tararua Pharmacy] the opportunity to alert Collins' daughter to the difference in strength and dosage, or to question the GP at [Ōtaki Medical Centre] about the difference."
Health NZ told Wilton it was making progress towards centralising dispensing records, but ultimately depended on funding allocation.
Wilton said the Health and Disability Commissioner made recommendations to both the Ōtaki Medical Centre and Berrys Tarurua Pharmacy for future changes, and that the commissioner was satisfied this had been met.
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