BACKGROUND: A 26-year-old with severe asthma – Ms B – is going on holiday to Brazil in two weeks and attends the pharmacy at her GP practice to collect an emergency travel pack put together by the in-practice dispenser – Ms K. In addition to her regular medication Ms B is provided with an emergency supply of steroids (prednisolone) and a seven-day dose of amoxicillin.
Four days before her holiday Ms B speaks to the practice nurse in regard to the emergency pack. The nurse provides instructions on use but advises Ms B to attend a local clinic for any urgent health concerns.
Ms B enjoys her holiday without incident but five days after returning she phones the surgery from home feeling unwell. She has a telephone consultation with a GP – Dr D – and reports having green catarrh and chest pain/tightness. She is also suffering with low back pain/urinary frequency and thinks it might be a UTI. Dr D offers advice on adjusting her asthma medication and asks what medications she has to hand in her unused emergency pack. The GP suggests starting the prednisolone and amoxicillin and attending the practice for review after the weekend if no better.
Later that day Ms B is taken to hospital by her boyfriend with vomiting, sweating and tongue/lip swelling – and she later faints in the emergency room. The symptoms occurred almost immediately after taking the antibiotic. It transpires that Ms B has a known amoxicillin allergy and should have been provided clarithromycin in the emergency pack. She is treated for anaphylaxis and spends the next three days in hospital.
A letter of claim is received by the practice alleging clinical negligence in the misprescribing of amoxicillin to Ms B. Solicitors acting for the patient claim that the practice failed to dispense the correct medication despite being aware of her amoxicillin allergy. It is also alleged that Dr D failed to provide competent medical advice in the telephone consultation and neglected to enquire about known allergies/contraindications before advising she take the antibiotic.
The resulting anaphylaxis led to hospital admission and a life-threatening medical condition with considerable discomfort and distress. Ms B reports recurring panic and low mood.
ANALYSIS/OUTCOME: A primary care expert is instructed to provide a report on the case and notes a clear failure by the dispenser (Ms K) to check the patient’s allergy history and provide the correct antibiotic. This is an obvious systems failure that the practice has already addressed in a significant event analysis (SEA) – and one for which all the practice partners are vicariously liable.
The expert is sympathetic in regard to Dr D actions, as the GP did not prescribe the antibiotic but only suggested the patient take what had already been provided by the practice. In such circumstances there would have been no call to check an allergy history. However, Ms B’s decision to take the amoxicillin was based on the GP’s advice to treat an undiagnosed UTI, which was a different reason for which the drug was originally prescribed.
MDDUS agrees to settle the case on behalf of and in agreement with the practice partners.
- Ensure allergy/contraindication alerts are working on practice systems and properly actioned.
- Prescribing staff should routinely check for allergies before prescribing an antibiotic.
- Give careful consideration to the need to examine a ‘phone-in’ patient before diagnosis and treatment.
- Conduct an SEA to ensure practice prescribing procedures are failsafe.
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