Hospital criticised over death

DAVID ALEXANDER/The Press

COMPLICATIONS: Karen Cramp died from side-effects of the anti-psychotic drug clozapine.

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A coroner has criticised Christchurch's Hillmorton Hospital after the death of a patient from complications due to her psychiatric medication.

The woman's GP has also been criticised for failing to chase up overdue blood test results which saw her fatal condition go undetected for several crucial days.

Christchurch woman Karen Cramp, 47, died in Christchurch Hospital on October 14, 2004 after the antipsychotic drug she was taking lowered her natural immunity.

Coroner Trevor Savage yesterday released the findings of Cramp's inquest to The Press.

They showed Cramp died of a severe depletion of white blood cells, caused by taking anti-psychotic medication clozapine.

The report concluded Hillmorton Hospital failed Cramp by not sending her regular blood test results to her GP, as it had promised, so her doctor could monitor her sometimes abnormal levels.

The report also criticised Hillmorton for failing to provide Cramp's GP with information about the dangers associated with clozapine, which can be prescribed only by psychiatrists.

The coroner's expert medical witness, Otago Medical School professor of general practice Murray Tilyard, told The Press this case was important because it highlighted the lack of information provided to GPs about clozapine and other specialist and often dangerous medications.

There are 34,000 clozapine prescriptions filled yearly in New Zealand for an estimated 5000 to 6000 patients, according to Pharmac.

The coroner's report said Cramp went to her doctor, Mark Henley, on October 4 after being bedridden with flu-like symptoms and fever for six days.

While Henley knew Cramp was taking clozapine he was unaware of the drug's serious risks.

He consulted a medical guide and subsequently sent Cramp for a blood test.

However, Henley did not mark the test request urgent or tell the laboratory Cramp was taking clozapine. Henley also failed to follow up when the results did not arrive at his surgery the following day, the report said.

While the inquest findings said Henley's actions in relation to the blood test were less than ideal, it praised him for consulting a medical guide to find out the dangers associated with clozapine.

Cramp's stepdaughter, Colleen Herriott, said although there was "series of errors" contributing to the death, the family felt most let down by her GP.

"He was the one she went to, he was the one she trusted," Herriott said.

"The hospital told her to go to her GP if she was sick and when she did, he didn't help her. Even if he didn't know about the drug he should have got in contact with Hillmorton Hospital and found out."

Henley declined to comment on the inquest report.

The coroner recommended medical bodies such as the Royal Australian and New Zealand College of Psychiatrists, ensure GPs were in future fully informed about about the dangers of clozapine.

The coroner also recommended the College of General Practitioners ensure its members provided full and appropriate information on laboratory test requests.

The Canterbury District Health Board's chief of psychiatry, Phil Brinded, said Cramp's death led to a review to understand how to prevent another such tragedy occurring.

It implemented an action plan including things such as improvement of information sent to GPs about medication and blood test results, Brinded said.

- © Fairfax NZ News