Dermatologist clinic criticised after giving woman burns by mixing up patient names

The woman woke up vomiting and struggling to breathe following the phototherapy appointment. Photo: 123RF

A woman received extensive burns to her skin after a staff member at a dermatology clinic accidentally typed the wrong name into the system, giving her a significantly higher dose of phototherapy treatment.

The woman was later admitted to the emergency department after waking up vomiting and struggling to breathe but said she did not receive an explanation for what had happened until months after the incident and is yet to receive an apology from the clinic.

The dermatology clinic has today been found in breach of the Code of Health and Disability Services Consumers' Rights for failing to provide services with reasonable care and skill.

The woman, identified as Mrs B, was receiving treatment for her psoriasis, a skin condition that causes scales and itchy, dry patches, at a dermatology clinic, which cannot be named.

In March 2020, Mrs B commenced narrowband UVB treatment, a form of phototherapy used to treat skin diseases, following the advice from her dermatologist, Dr A.

The treatment involved three sessions weekly in which Mrs B stood in a machine with fluorescent light tubes, with the dose increased by 10-15 per cent increments automatically.

The clinic told the Health and Disability Commissioner that when a patient presents to the clinic for treatment, they check in at the front desk and give their name. The patient is then given goggles and asked to proceed to the treatment room.

In July 2020, Mrs B attended her ninth session on a Friday, as the Covid lockdown delayed her treatment. Her last treatment was approximately two minutes in length, however, when she stepped into the machine an automated voice said the session would be approximately eight minutes long.

Mrs B said she was surprised to hear how long the treatment would be but did not question it and remained in the machine, where she "assumed everything would be fine".

As a result, Mrs B received 3135 m joules rather than the planned 825 m joules.

Afterwards, she mentioned to the reception staff that the eight-minute session seemed "strange" to her and said one of the receptionists looked surprised and replied, "Eh?"

One of the receptionists told HDC they informed Mrs B to "report back if there were any problems".

After Mrs B's burns, an incident evaluation report revealed that the two reception staff working on this day were less experienced in managing a busy front desk unassisted, as the most experienced staff member was on leave.

Later that day Mrs B's skin began to feel itchy and dry around her neck and waistline and her body was red all over, except for her feet and palms of her hands.

She contacted the clinic and was told the practice manager, who was in a meeting at the time of the call, would call her back. However, Mrs B received a call from the receptionist who said she could not speak to a doctor as they had all left for the day.

She was advised to apply aloe vera gel to her skin and was offered an appointment with Dr A on Monday. She was also told to consult her general practitioner or an after-hours clinic if her condition worsened.

Throughout the evening, Mrs B applied a homemade yoghurt and egg white remedy to the burn, used sunburn spray and had cool showers to soothe the burns. When her skin worsened, her husband took her to an after-hours accident and medical clinic.

There, she was diagnosed with superficial but extensive burns across the body post-UVB treatment. She received moisturiser, pain relief and a referral letter to go to the public hospital if the pain did not subside.

Mrs B returned home and went to sleep, but woke up at 3am vomiting and struggling to breathe. She was rushed to the emergency department but was discharged with pain relief and Sorbolene cream after a blood test and stomach examination showed normal results.

Mrs B told HDC that throughout Saturday and Sunday she was in great pain and discomfort, and felt no improvement.

On Monday Mrs B returned to the dermatology clinic to speak with Dr A, who she said was "avoiding" the topic of the burns and did not apologise to her, despite Dr A telling the HDC he did apologise.

Dr A also said he prescribed prednisone - a steroid medication - to help with inflammation, and recommended cool baths and Locoid Lipocream10 to be applied to tender areas.

Later that day, Mrs B received a text from the clinic that stated the UVB phototherapy machine would no longer be available as staff thought that might have been what caused Mrs B's burns.

Mrs B returned to the clinic on Tuesday after her skin had begun to peel and become red and tender on her neck, breast and buttocks.

She told HDC that Dr A told her she would be better by Thursday and was encouraged to take cool showers but Dr A said he would never have predicted such a rapid recovery instead he agreed to see her daily until she was comfortable.

Two days later Mrs B said she returned to the clinic and asked how the burns had happened and was told the machine was having calibration issues.

Dr A told HDC he informed Mrs B of the human error that caused her burns on August 3, as soon as he found out himself.

However, Mrs B said the first time she was told about the wrong name being typed into the machine was when she read Dr A's statement to HDC.

On August 28 an incident evaluation report was completed, shortly after Mrs B made her complaint to the HDC, which confirmed the cause of Mrs B's burns was due to the wrong name being typed into the system and it was possible this error could happen again.

Dr A told HDC that the receptionist cannot remember how she typed the wrong name into the system but was under "considerable pressure" at the time.

Mrs B told HDC that at no time has the practice manager offered any apologies for these events directly to her.

"[Dr A] was slow to apologise, and only when I kept bringing up the fact that I had not been contacted or offered an explanation, he offered me a quick apology then moved the conversation on... I continue to await a direct apology."

The clinic told HDC that while it agrees that an error was made by a staff member who was less experienced than its senior receptionist, it would not classify the staff member as inexperienced.

The clinic also said that the machine is now overdue a service because of Covid-19-related delays, and has not been in operation.

Dr A said they would like to "reiterate the clinic's apology" to Mrs B "for the deficiencies in the care she received".

"We accept that these shortcomings resulted in [Mrs B] suffering superficial burns and also acknowledge the distress these events have caused her."

Deputy Health and Disability Commissioner Dr Vanessa Caldwell concluded the clinic's failure to supervise and train staff adequately led to the initial error, as well as their inappropriate actions afterwards, and therefore found them in breach of the Code.

"I consider staff at the clinic were not supported or trained in their role adequately to provide safe care. As a result, the woman was given another patient's dose, and was not provided with medical advice on how to treat her resulting redness and burns."

Caldwell was also critical of the clinic for failing to investigate the cause of the machine error, for not informing the woman of the cause of the error and for failing to apologise to her in a timely manner.

After taking into account the improvements made to their service, Caldwell further recommended the clinic ensure the individuals involved provide a written apology to the woman and improve policies around staff training and the UVB set-up.