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Administration and documentation of medication to prison inmate (13HDC00853)
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(13HDC00853, 26 June
Prison health care ~ Registered nurse ~ Doctor ~ Dental
procedure ~ Pain management ~ Administration ~ Documentation ~
A 30-year-old man was an inmate at a correctional facility. The
man had a dental procedure, following which he continued to bleed
from the wound, was vomiting, and experiencing hot and cold
Over the following 50 days, the man continued to experience pain
resulting from the procedure and submitted written requests for
clinical review or pain relief on five occasions. The man also
recalls making verbal requests to facility staff on a number of
occasions for medical review, pain relief, or for antibiotics to be
On the day following the procedure, the man was prescribed Pamol
twice daily as required, however there are no records of the
administration of Pamol. The man was then prescribed Pamol three
times daily for eight days following the procedure, however it is
recorded that he received Pamol four times in total.
Following the procedure, the man was prescribed Brufen twice
daily as required, however it is recorded that he received Brufen
three times in total. The man was then prescribed Brufen three
times daily over eight days, however it is recorded that he
received Brufen 25 times in total. During this time, the man
received Brufen five times a day on two consecutive days and, over
the next six days, it is recorded that the man received Brufen on
ten occasions in total. However, there is no record of why he
received Brufen on these occasions.
Following the procedure, the man was prescribed Augmentin three
times daily for nine days. He should have received 27 doses,
however it is recorded that he was administered Augmentin on 12
occasions in total. It is recorded on only one day that he was
administered Augmentin three times as prescribed.
Following the procedure, the man was prescribed metronidazole
three times daily for eight days. He should have received 24 doses,
however it is recorded that he was administered metronidazole on
eleven occasions in total. It is recorded on only one day that he
was administered metronidazole three times as prescribed.
For a period of 26 days, the man was prescribed naproxen and
Voltaren for pain. There is no record that either naproxen or
Voltaren were administered to the man on any occasion.
It was held that facility staff consistently failed to provide
the man with medication in accordance with his prescription, and
repeatedly failed to assess him prior to administration of
medication. There was a pattern of suboptimal clinical
documentation by multiple staff involved in the man's care, which
indicated a lax attitude towards documentation within the facility.
The facility failed to ensure that the man was provided services
with reasonable care and skill and breached Right 4(1).
The Department of Corrections was referred to the Director of
Proceedings.The Director of Proceedings filed proceedings by
consent against the Department of Corrections in the Human Rights
Review Tribunal. The proceedings were resolved by negotiated
agreement which included the Tribunal issuing a declaration that
the Department breached Right 4(1) by failing to provide health
services with reasonable care and skill.
Adverse comment was made about the facility for placing the man
on a soft diet for three days without any plan to review him before
placing him back on a regular diet. Adverse comment was also made
about a doctor for documentation errors relating to