Auckland man with bipolar rushed to hospital after six doctors failed to manage medication

This report highlighted the importance of appropriate prescribing and providing adequate information to patients. Photo / File

A man in his 70s living with bipolar was rushed to hospital in a serious condition after six doctors did not monitor his medication correctly.

During 24 visits to his Auckland medical clinic - Radius Ti Rakau Limited - all six doctors also failed to recognise his renal function was deteriorating over a two-year period.

The Health and Disability Commissioner found Radius Ti Rakau Limited in breach for repeated failure by multiple general practitioners (GPs) to prescribe appropriately and to monitor lithium levels and renal function between 2014 to 2018.

As a result, the man was rushed to hospital on June 27, 2018, with weakness, shortness of breath, slurred speech, tremor and confusion. He was diagnosed with acute kidney injury secondary to lithium toxicity.

It was noted that his lithium levels had not been checked since May 23, 2014.

In the report, the manager of the medical centre told HDC: "As a clinic, we deeply regret that we let [Mr A] down and failed to regularly monitor his lithium levels."

The Commissioner said this report highlighted the importance of appropriate prescribing and providing adequate information to patients, as well as the need for communication between general practitioners.

The medical clinic were told to write a letter of apology to the man and to audit all patients on medications that require regular blood tests to check for toxicity.

It was also instructed that all staff involved in the management of the man meet to discuss the findings of this report, including the importance of monitoring lithium, reviewing patient notes before prescribing medication, and following the Medical Council of New Zealand's "Good Prescribing Practice" guidelines.

In response to this complaint, Ti Rakau made the recommended changes.