Prescribed drug led to 80-year-old's death

The man was prescribed diclofenac for ankle pain. Photo / Thinkstock

An 80-year-old man suffered organ failure and died after being prescribed diclofenac for ankle pain - despite a warning against the drug being placed on his medical file five years earlier when it was thought to have caused deterioration of his kidney function.

Diclofenac is sold under several brand names, including Voltaren. The man did not realise the two names referred to the same active ingredient, according to a report on the case made public this afternoon by Health and Disability Commissioner Anthony Hill.

"The GP prescribed a two-week supply of diclofenac - trade name Voltaren - and advised the man to return in one month for a blood test to check his renal function," the commissioner's office said.

The earlier warning on the man's clinical file stated: "Diclofenac sodium - renal failure/retention - avoid". The GP saw the man later in the year in which the warning was written and had recorded, "Note renal impairment with addition of Diclofenac".

But the GP stated that at the ankle-pain consultation he did not recall the man's previous reaction to diclofenac and did not remember a warning coming up on the computer system. Due to the merging of the medical centre with another practice at the time and possible computer difficulties in the lead up to, and during the merger, the warning may not have featured.

The man, who was on several medications, returned the following month with joint pain in his right foot. The GP diagnosed probable gout and recommended continuing with diclofenac. When, two days later, the man returned, complaining he was unable to pass urine, the GP diagnosed urinary retention and referred him to hospital.

There, he was diagnosed with renal failure. Signs of multi-organ failure emerged and he died.

Mr Hill said the GP acted without reasonable care and skill - by failing to establish the man's medical history by adequately questioning him or reviewing his clinical notes, by not taking sufficient regard of his associated risks, and by inadequately monitoring his renal function when prescribing diclofenac.

He recommended the GP undertake training in good prescribing; that the Medical Council consider reviewing his competence; and that the GP's medical centre check back to ensure no other "critical alerts" were missed at the same time as the man's diclofenac warning was overlooked.