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Overdose of testosterone administered to infant with congenital adrenal hypoplasia (04HDC03355)

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(04HDC03355, 3 May 2005)

Registered nurse ~ Medical centre ~ Overdose ~ Testosterone enanthate ~ Congenital adrenal hypoplasia ~ Scope of practice ~ Protocols ~ Regional differences ~ Communication ~ Vicarious liability ~ Professional standards ~ Rights 4(1), 4(2)

Soon after birth, an infant was diagnosed with adrenal hypoplasia, an extremely rare congenital condition. The condition was well controlled with regular medication, but a paediatric endocrinologist in a larger city suggested that the infant undertake a short course of testosterone to ensure normal phallus growth. Three 25mg injections of testosterone enanthate were to be administered one month apart. The specialist's standard practice was to write a prescription for the parents to fill and take to their GP's nurse, who would administer the course of injections. The specialist did not include specific instructions with the prescription, as he considered it a straightforward drug to administer. The specialist's letter of assessment to the boy's paediatrician and GP did not mention the testosterone treatment or the dosage, and delays meant that the letter was not received before the prescription was filled and administered.

Although the specialist discussed the proposed testosterone treatment with the boy's local paediatrician, the paediatrician did not send the boy's GP written instructions about the treatment, as it was always his intention to administer the injections at the hospital as per local practice.

The delays in communication meant that the first injection was administered, correctly, by a nurse at the medical practice. The next injection, administered by another practice nurse, was administered at 10 times the prescribed dose. When the nurse then went to document the procedure, she recognised her mistake and told another nurse, who alerted the boy's GP. The family was alerted, the overdose monitored and managed, and the nurse apologised.

It was held that the nurse did not take reasonable care or comply with the standards expected of a registered nurse, and in doing so breached Rights 4(1) and 4(2). The medical practice was not vicariously liable for the nurse's breaches.