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Inappropriate prescribing and inadequate assessment of patient with suspected gastrointestinal bleeding (10HDC00753)

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(10HDC00753, 15 June 2012)

General practitioner ~ Inappropriate prescription ~ Informed consent ~ Gastrointestinal bleeding ~ Assessment ~ Transport to hospital ~ Documentation ~ Rights 4(1), 4(2), 6(1)(b), 7(1)

A 63-year-old man complained about the care provided to him by his GP and another doctor at the same medical practice. The man had a history of two episodes of peptic ulceration associated with bleeding. This history was known to his GP and was also recorded in the man's clinical notes.

The GP overlooked the man's history and prescribed him ibuprofen, a drug that Medsafe advises should not be used in patients with a history of recurrent peptic ulceration or gastrointestinal haemorrhage. The GP also prescribed prednisone, which Medsafe advises should be used with caution in patients with peptic ulcers. The GP did not inform the man about the possible risks and side effects of the medication he was prescribing.

Later that month, the man consulted another doctor at the same practice complaining of chest pain and feeling unwell, and advising that he had been having black bowel motions. The second doctor assumed that the man had suffered a gastrointestinal (GI) bleed secondary to ibuprofen and prednisone. The doctor ordered blood tests, advised the man to stop taking the medication and to go to the hospital's emergency department if his condition worsened. The doctor did not explain what symptoms to be alert to or measure the man's blood pressure at the consultation.

The following day the man's partner contacted the medical practice for advice, as the man was feeling worse. The second doctor instructed the man to go to hospital but did not advise him to call an ambulance to transport him. The man travelled to the hospital's emergency department by public transport. On arrival at the hospital, the man's haemoglobin was 54g/L, indicating acute blood loss, and he was given a blood transfusion and intravenous omeprazole. The man had a gastroscopy and was diagnosed with an upper GI bleed, secondary to non-steroidal anti-inflammatory drugs (NSAIDs).

It was held that the man's GP breached Right 4(1) for prescribing NSAIDs and steroids to a patient who had a known history of two episodes of peptic ulceration. The GP also breached Right 6(1)(b) for failing to inform the man about the possible risks and side effects of the medication he was prescribing. Without this information, the man was not in a position to provide informed consent to taking the medication. Accordingly, the GP also breached Right 7(1).

The second doctor breached Right 4(1) for failing to measure the man's blood pressure at the consultation, failing to seek immediate hospital admission for the man following the consultation, and failing to ensure the man was aware of the seriousness of his condition the following day and that he should call an ambulance to transport him to hospital. The second doctor's documentation in relation to the consultation was inadequate and, accordingly, he breached Right 4(2).

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