Corrections at fault over inmate’s heart attack, hospital stays

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The Health and Disability Commission has found the Department of Corrections failed to give a prisoner regular medication resulting in five hospitalisations, a heart attack and four stents.

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An inquiry has found poor compliance with policy and a concerning lack of critical thinking from Corrections staff seriously impacted on a prisoner’s health. Photo: 123RF

He was prescribed a long-term medication to reduce the risk of heart disease and stroke but the report found Corrections had failed to administer the drug, Clopidogrel, at three separate times.

He was prescribed the medicine after he had a stroke, it was then only given for a month before it was stopped in error.

Several months later he was re-admitted to hospital after suffering a heart attack and had four stents put in.

Following this the drug was given again, but only for two months before it was stopped incorrectly.

The report said it was not until several months and three hospitalisations later that he began to receive the medication again.

Deputy Health and Disability Commissioner Kevin Allan drew attention to several failings he said represented a pattern of poor compliance with policy and a concerning lack of critical thinking.

Allan noted that under the Corrections Act a “standard of health care that is available to prisoners in a prison must be reasonably equivalent to the standard of health care available to the public”.

He said prisoners did not have the same choices or ability to access health services as a person living in the community.

“They do not have direct access to medication or to a GP. They are entirely reliant on the staff at Corrections’ health services to assess, evaluate, monitor, and treat them appropriately.”

Allan recommended:

  • There should be an independent, external review of the level of GP cover provided at Auckland Prison
  • Corrections should report new processes for medication self-administration signing sheets to the Health and Disability Commission
  • Corrections should review a sample of recent discharges from hospital to Auckland Prison to ensure that appropriate care plans are in place

Pharmacy, doctor also criticised

The failings were extended to Clendon Pharmacy and a doctor who were also found to be in breach of the Code of Health and Disability Services Consumers’ Rights.

The Deputy Commissioner identified a number of deficiencies in the care that Clendon Pharmacy provided to the man including:

  • Dispensing the medication without a current medication chart
  • Discontinuing the medication when it was charted to continue
  • Not having internal procedures in place for processing orders from Corrections

He was also critical of the doctor incorrectly transcribing the hospital prescriptions which contributed to the man not receiving Clopidogrel for as long as was intended.

Corrections and Clendon Pharmacy each gave the man a written apology.

The case was referred to the Director of Proceedings to decide whether any legal proceedings should be taken against Corrections.

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