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Auckland DHB’s ambiguous discharge notes linked to woman’s stroke

The Auckland District Health Board has been ordered to apologise to an elderly woman after a stroke she suffered was linked to “ambiguity” around medication instructions on her hospital discharge summary.

In a report released today, Health and Disability Commissioner Morag McDowell found the DHB in breach of the Code of Health and Disability Services Consumers’ Rights and has put forward a number of recommendations.

The woman – in her eighties – presented to the Emergency Department in May 2018 because of rectal bleeding. She had a history of atrial fibrillation, a condition that affects the heart, and was taking medication to reduce her risk of stroke. The report said the woman had large bowel motions with large amounts of bleeding.

The next day the medical team withheld her medication, called dabigatran. A general practitioner that examined the woman was concerned that dabigatran reduces the ability of blood to clot and there is a risk of prolonged bleeding, the report said.

For two days in hospital, the woman’s condition remained stable while she waited for a colonoscopy, apart from once when she passed blood in her bowel movements.

With no evidence of further bleeding after the colonoscopy, the woman was discharged on the third day. A medication prescription given to her did not include instructions on taking dabigatran again.

When the woman inquired, a nurse tried to speak to the medical team but was unable to before the woman was discharged. The nurse told the woman to see her GP if she had not been contacted by the following day. She was not contacted. The woman’s GP said she could return in two weeks’ time for a review and he would restart her on dabigatran.

Three days later she had a stroke and was readmitted to hospital. It had been 12 days since her last dose of dabigatran.

The DHB said instruction to her GP for “no change to regular medication” was intended to include the dabigatran, but in hindsight accepts that advice caused ambiguity.

Auckland DHB has acknowledged the discharge summary did not explicitly state that dabigatran should be restarted. The DHB said the medication could have been restarted because it had already been held for one week.

“There was no statement recorded in the medical notes that there should be a departure from this practice in [Mrs A’s] case … We apologise to [Mrs A] and her family for the team’s lack of clarity in regards to the restarting of [dabigatran],” said the clinical director in the report.

A general surgeon who provided independent expert advice to the report, Dr ChristoffelSynman, said: “To have left the decision up to her GP to make was inappropriate and an abrogation of duty of care.

“If specialists dealing with this particular problem couldn’t firm up a clear decision and treatment plan, it would have been unfair to expect the GP to have this conversation and come up with a plan.”

Auckland DHB has acknowledged its clinical notes needed improving and a safety-netting process be established to avoid a similar situation.

It has since created an electronic medication history form for more accuracy, populatedfrom the community pharmacy dispensing records.

“The eMR informs the electronic discharge summary and alerts the medical team to admission medication that has been withheld during admission. This provides a prompt to reconcile and review the need to continue any withheld medication,” the report said.


In her report, Commissioner McDowell is critical of the DHB’s lack of a “clear plan” for the woman’s anticoagulant management. She said some staff members hold “some degree of responsibility for their failings” and she considers “that the deficiencies outlined above indicate poor discharge planning processes, for which ADHB is responsible”.

“In my opinion, ADHB failed to provide services to Mrs A with reasonable care and skill”.

It has been recommended that the DHB use McDowell’s report today as a case study for nurses and doctors, and wider education be provided to house officers on the discharge summary.

McDowell also recommended the DHB provide the Commission with the outcome of a review of its new electronic medical record programme, and consider sharing the redesigned electronic discharge summary with other DHBs.

Auckland DHB has been recommended to provide a written apology to the woman’s family and sent to the Health and Disability Commissions within three weeks of the report.

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