A doctor prescribed morphine to a woman, despite her having stated, in writing, that she was allergic to the drug.
Health and Disability Commissioner Anthony Hill, in a report published today, says the unnamed doctor breached the code of patients' rights.
The woman was aged 38 when she slipped and fell in the shower injuring her left foot and ankle in 2014. The following day, her GP referred her to a hospital emergency department.
On arrival, she completed an admission form on which she wrote in response to the question, "any medical alerts or allergies?" that she was allergic to morphine, codeine, penicillin and erythromycin.
An x-ray showed no obvious fracture, but a query was raised about a possible displacement of bones within the foot and a review was requested from the orthopaedics team.
The doctor, a locum, prescribed Sevredol and discharged her home. He did not ask her if she had any allergies, nor did he explain that Sevredol is a form of morphine.
Before she took any Sevredol, her mother, a nurse, recognised that morphine had been prescribed and contacted the ED.
"While I accept that Dr C undertook a good assessment of Ms A's injury," Mr Hill said, "he prescribed Sevredol to her inappropriately, despite her well documented allergy to the drug. In my view, Dr C failed to do the basics and missed several opportunities to ascertain Ms A's allergy status, by not reading the notes and by not asking Ms A whether she had any allergies."
The doctor failed to ensure the woman was given information a reasonable patient would expect, so could not give give her informed consent to the treatment.
The doctor was required to undertake training in taking a patient's history, and in safe prescribing practices. He was also required to make an apology to the woman.
Mr Hill's report said the doctor had been practising medicine since 2008. "Dr C is no longer practising in New Zealand and does not currently hold a New Zealand practising certificate."