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Health and Disability Commissioner
drug that he had given Miss C in theatre, knowing that she had experienced no problems
with it earlier.
Dr E was not involved in the initial diagnosis of dystonic reaction to Stemetil, made by Dr L
and Dr D. However, on the afternoon shift, Ms K contacted Dr E and informed him that Dr
D and Dr L had attended to Miss C and diagnosed a dystonic reaction to Stemetil.
Dr E was contacted by Mrs M again shortly after she arrived to special Miss C at about
6.00pm. At that time, Dr E verbally ordered more Cogentin to be given. The drug chart
records that 0.4mg of Cogentin was administered intravenously at 6.29pm. About 7.30pm,
after Miss C had fitted again, Mrs M contacted Dr E once more and he arranged for a
further dose of Cogentin to be given. The drug chart records that a reduced dose (0.1mg)
of Cogentin was administered intravenously at 7.30pm.
My anaesthetist advisor considered that Dr E’s decision to prescribe further Cogentin when
Miss C’s fits continued was in accordance with standard practice as dystonic reactions may
require repeated doses. My advisor also informed me that Dr E’s order for a further dose of
Cogentin was the correct response to the diagnosis made by other medical practitioners,
having regard to the information relayed to him over the telephone by Mrs M.
When Dr E arrived at 8.30pm, Miss C appeared to be in a post-ictal state and unconscious.
While he was examining her she had an epileptic type seizure and Dr E decided to transfer
her to the Intensive Care Unit at the public hospital. At 8.45pm, prior to transferring Miss
C to the public hospital, Dr E prescribed IV Valium to stop her fitting. My anaesthetist
advisor considered that Valium was the correct choice of drug. My advisor also noted that
when Dr E did examine Miss C, it was clear to him that the original diagnosis was in doubt,
and that his course of action from then on was in accordance with good professional
practice.
I am guided by my expert advice. I accept that Dr E acted in accordance with good
professional practice in his management of Miss C’s condition. He responded appropriately
to the information relayed to him by telephone by the ward nurses, and responded
appropriately when he physically examined Miss C later that evening. Accordingly, in my
opinion Dr E provided anaesthetic services to Miss C with reasonable care and skill and did
not breach Right 4(1) of the Code.
Opinion: No breach – Mr F
Rights 4(1) and 4(2)
In my opinion Mr F did not breach the Code.
Mr F set up Miss C’s drip in theatre under the guidance of the anaesthetist, Dr E. Dr E
prescribed the rate of IV fluid to Miss C at 80mls per hour. The IV was assembled by Mr F
24 18 June 2002
Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and
bear no relationship to the person’s actual name.