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Administration of medication to mental health patient (09HDC01408)
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(09HDC01408, 15 June
Mental health acute care unit ~ Public hospital ~ District
health board ~ Mental health ~ Dementia ~
Medication ~ Quantity ~
Deterioration ~ Neglect ~
Recordkeeping ~ Rights 4(1), 4(2)
The family of a 64-year-old man complained about the care he
received in a district health board's mental health acute care
unit. The man was admitted under the Mental Health (Compulsory
Assessment and Treatment) Act 1992. He was floridly psychotic and
considered a risk to himself and others.
Various types of medication were trialed but were unsuccessful
in controlling his delusions. The man began refusing all oral
medication so it was decided to give him the drug fluphenazine
deconoate (fluphenazine) by injection.
The records were unclear but the man was administered at least
162.5mg of fluphenazine over a period of up to 40 days. The
manufacturer's recommended dose for people aged over 60 years is
6.25mg for a test dose and subsequently ¼-⅓ of the normal dose
which equates to 22-75mg every three weeks.
After an initial improvement, the man's physical and mental
functioning suddenly deteriorated. He had increasing body
stiffness, stooping posture and a Parkinsonian gait, decreased
mobility, a mask-like face, slow thinking and speech and a lack of
attention to physical cleanliness. He never again was able to
recognise his family. He was often left un-showered and wearing
dirty clothes. He continued to deteriorate and, sadly, died.
It was held that the district health board gave the man more
than the recommended quantity of medication for a man of his age
with dementia and, as it had failed to provide fluphenazine with
reasonable care and skill, it breached Right 4(1) of the Code.
It was also held that the district health board breached Right
4(2) for failing to clearly record the administration of
fluphenazine and breached Right 4(1) for failing to have a clearly
defined plan and strategy to manage the man's behaviour and hygiene
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