A mum in her 50s with a history of depression died tragically after her general practitioner (GP) prescribed her a "dangerous" amount of medication.

She left behind her husband and daughter.

The GP has apologised to the family for the failure and has since changed her appointment times with mental health patients from 10 minutes to 30 minutes, following an investigation by the Health and Disability Commission (HDC) into the woman's care.

A HDC report, published today, found the GP in breach of the Code of Health and Disability Services Consumers' Rights for giving a woman access to a potentially dangerous quantity of medication.

Names and certain details of the case have not been published for privacy reasons.

Mental Health Commissioner Kevin Allan said that the GP gave the woman access to a quantity of medication that could be misused dangerously and increased the risk of harm to the woman.

The woman, who had a long history of substance addiction and mental illness, including suicidal ideation, was taking prescribed mirtazapine and paroxetine in 2017.

The prescription said that she should take one tablet of each medication per day, and authorised the pharmacy to dispense her fortnightly repeats of 14 tablets of each medication.

A few months later, the woman moved with her family to another region where she saw a new GP and requested a repeat of her prescription, which the GP granted.

When the woman arrived at the pharmacy, she asked to be dispensed a three-month quantity. The request was conveyed to the GP, who, without reviewing the woman personally, manually changed her prescription to allow the pharmacy to dispense 90 tablets of each medication.

Allan criticised the GP's repeated failure to document important aspects of the services she provided to the woman and said the GP failed to comply with professional standards.

"It was not appropriate for [the GP] to prescribe [the woman] the quantity of medication she requested without first reviewing her (or arranging for another suitable doctor to review her) and establishing that she was safe to receive it."

Allan recommended that the GP reflect on her failings and report on changes to her practice, undertake further education on the subject of safe prescribing, and apologise to the woman's family.

He also advised that the medical centre investigate whether its GPs have been documenting their manual changes to prescriptions appropriately, and consider whether further policies concerning manual changes to prescriptions are necessary.

In the report, the GP said: "I am truly sorry … and I accept that my documentation was below standard in this particular case and I have taken steps to ensure this doesn't happen again."

She said she was "now much stricter with quantity dispensing of psychotropic medications and ha[s] declined every single request from patients that would rather have the full content of the script".

She now allocates 30 minutes for all mental health patients and has stopped taking double bookings to give her more time with each patient. She also spends half an hour per day reviewing her notes.

 

Where to get help:

• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111.