Wrong drug led to man's death
An elderly dementia sufferer died after a doctor gave him an anti-psychotic drug, which triggered a lethal disorder, without thoroughly reading the hospital notes.
Coroner Chris Devenport found that David Jackson, 76, died from pneumonia caused by a neurological disorder triggered by a drug used to sedate him.
Jackson was admitted to Princess Margaret Hospital in July 2011 after an episode of confusion. He suffered from lewy body dementia (LBD) and Parkinson's disease.
Four days later, Dr David Bruce was called in to see Jackson as he had become ''aggressive and difficult to control''.
Bruce requested security but was told there was no security available at the hospital.
He then requested the drug midazolam be given to Jackson to calm him, but was told it was not stocked on the ward.
Bruce then administered Jackson the lowest possible dose of the only drug available, haloperidol.
Jackson was then transferred to a ward under the care of consultant Dr Chris Collins. However, his condition soon deteriorated and he died five days later.
Collins said Jackson died from pneumonia but that it was probably caused by neuroleptic malignant syndrome (NMS), a disorder usually triggered by an anti-psychotic drug.
Patients with LBD are ''hyper-sensitive'' to anti-psychotic drugs and are at risk of NMS.
Bruce was aware of the risks of haloperidol, but he was not aware Jackson suffered from LBD when he gave him the drug, although it was written in his hospital notes.
Bruce said he was not aware that such a small dose of the drug could have such a harmful outcome, although when he later became aware of Jackson's condition, he cancelled a second prescribed dose.
Professor Martin Pollock, who provided the coroner with his medical opinion, said a ''strong case could be made that Jackson had NMS triggered by haloperidol, which resulted in his death".
Pollock believed Bruce should have read the hospital notes properly as he had ''no prior knowledge of the patient".
The guidelines for managing LBD were reviewed after Jackson's death, but the coroner recommended that the Canterbury District Health Board also review the availability of drugs for sedation and the provision of security staff at Princess Margaret Hospital.
He found that having security personnel to control Jackson may have given Bruce more opportunity to review the hospital records and ''may have resulted in a decision not to administer haloperidol to him".
He noted that the drug Bruce originally asked for, midazolam, would not have had the same adverse reaction.
- © Fairfax NZ News
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