The Health and Disability Commissioner has found a DHB in breach of the Code after a doctor failed to make it clear that his patient needed to take a trial dose of a medication before he was discharged.  The Commissioner commented that the case demonstrated "a failure to do the basics well" and that "poor communication led to this situation".

A 74 year old patient with a history of asthma and chronic obstructive pulmonary disease was admitted to hospital with shortness of breath and an atrial flutter. A medical registrar prescribed sotalol as a prophylaxis but, because of potential side effects, the registrar had intended that the patient take a trial dose on the ward prior to his discharge.  However, the registrar did not communicate this to the patient and the documented treatment plan was not explicit. The patient was discharged quickly (in part because a shuttle was arriving to take him home) and his sotalol prescription was instead faxed to his local pharmacy. The patient took the sotalol alone at home and suffered an adverse reaction requiring emergency treatment.  While the Commissioner accepted that sotalol was an appropriate medication, the Commissioner criticised the doctor's failure to give clear instructions about the need for a trial dose.The Commissioner also criticised the doctor's failure to discuss the risks, benefits and need to take a trial dose with the patient, commenting that "provision of this information would have enabled [the patient] to be a partner in his own treatment". The DHB was found in breach of Rights 4 and 6 of the Code. 12HDC00599