GP stopped medication despite not fully reading medical history

Health and Disability Commissioner Anthony Hill, in a report published today, finds that the GP, whom he does not name, breached the code of patients' rights. Photo / File

A GP has been faulted for stopping the blood-thinning medication of a new patient - who later suffered a series of strokes and died - without reading the man's medical history in sufficient detail.

Health and Disability Commissioner Anthony Hill, in a report published today, finds that the GP, whom he does not name, breached the code of patients' rights.

The man was a patient of the GP for a number of years before transferring to a doctor at another clinic. After five years he transferred back to the original GP at whose clinic he was assessed as a new patient by a trainee intern.

The second clinic did not transfer the man's medical records in such a way as to ensure that the key documents could be easily identified, the commissioner's office said.

The intern, tasked with taking the man's medical history and physically examining him, did not elicit that he had had surgery to replace a heart valve and was consequently taking the blood-thinner warfarin.

The man later told the GP of the warfarin. The GP told the commissioner's investigation that when the man was asked why he was taking the drug, he gave a vague reply about its being for his heart. The GP assumed it was for a heart rhythm disorder, made no further checks and advised him to stop taking the medicine.

Four weeks later the man consulted the GP when he became concerned about his heartbeat and said he had taken warfarin tablets, which made him feel better. The GP again advised him to stop taking warfarin. The man died in hospital soon afterwards, having suffered several strokes.

Mr Hill said that the electronic copy of the patient's notes sent by the second medical centre - and reviewed by the GP - was incomplete and had important documents missing.

"However," Mr Hill said, "a complete set of paper notes was transferred to medical centre one. I am concerned that the paper notes were reviewed by the intern, and that important information was not identified."

The commissioner's medical adviser, Dr David Maplesden, noted that with a brief perusal of the notes - less than three minutes - in the order provided, he was able to establish that the patient, Mr A, had had valve surgery and that his medications included warfarin.

Mr Hill said: "In my view, it is clear that an adequate review of the notes did not occur in Mr A's case. Had [the GP] reviewed Mr A's medical notes in any detail, he would have been alerted to important aspects of Mr A's medical history, including his mitral valve replacement, and the fact that he had been prescribed warfarin and was undergoing INR [warfarin-related] monitoring."

The GP has undergone a Medical Council review, after which the council ordered he do a 12-month education programme. Mr Hill recommended that following the GP's completion of the programme the council consider whether a further review of his competence is needed.