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A paraplegic who died from lung disease caused by long-term use of a prescribed antibiotic should have been warned of the risk, the health watchdog has found.
In a just-released report, Deputy Health and Disability Commissioner Carolyn Cooper found several health professionals missed opportunities to ensure the man understood the risk of taking the antibiotic nitrofurantoin for more than six months.
The man, who had been paralysed several years previously in an accident, was first prescribed the drug in 2017 to treat recurrent bladder infections by a specialist at a spinal unit of a public hospital.
He took nitrofurantoin for around 28 months over a three-year period, before dying of pulmonary fibrosis - a rare side-effect of long-term use of the antibiotic.
His wife subsequently laid a complaint about this oversight against several healthcare providers, including the rehabilitation specialist at a spinal unit, a medical centre, his GP, a pharmacy and the urology department at a public hospital in another region.
"In concluding this investigation, I acknowledge and support her wish to prevent any further avoidable deaths that may be due to the adverse effects of nitrofurantoin," Cooper said.
She found the health professionals "shared responsibility for missed opportunities" to warn the man of the risk.
"Although I am very critical that none of the health service providers who cared for the man ensured that he understood the risks, I consider that no single individual or service was significantly more responsible," she said.
"All the healthcare providers who had a role in the prescribing and dispensing of nitrofurantoin to the man could have checked whether he was aware of the long-term risk at appropriate times, and it is concerning that this did not occur."
The specialist at the spinal unit told the HDC he "recalled" having informed the patient in July 2017 about the risk, but acknowledged there was no record of this discussion.
Other providers - including the GP and a urology registrar at another hospital - continued to prescribe it over the coming months and years through to 2019.
The man's wife told the HDC that after having taken nitrofurantoin for about six to eight months, her husband developed a mild and dry cough, but as they were not aware that this could be related to the nitrofurantoin, they did not raise any concerns about this at the time.
The government's drug safety agency, Medsafe, first published the risk of serious lung side effects associated with the use of nitrofurantoin back in 2002, and again in 2012.
However, the GP said he did not know about the risk of lung damage at the time.
"Had I been aware of the serious long-term side effects of this medication, I would have certainly performed a risk/benefit analysis."
The urology registrar said when he saw the patient, he was undertaking an unsupervised procedural clinic with limited time for in-depth clinical discussions or senior support.
"I was devastated to hear of [Mr A's] death. Any role I played in this process profoundly disappoints me. I feel a sense of responsibility for this and am immensely frustrated that my interaction with him wasn't the small moment that was needed to alter his trajectory away from premature death.
"These oversights are difficult for me to accept, however, they are tempered by the fact I was not the doctor who had initiated the prophylaxis regimen using nitrofurantoin, and also my knowledge that the patient was under the ongoing care of a urologist in private practice in [another region]."
The expert pharmacy adviser told the HDC the pharmacy should have informed the patient of the potential risk, but agreed there was a view among some in the profession that "time and cost pressures" do not allow that kind of role.
The pharmacy told the HDC: "As a community pharmacist, you have to trust that the prescriber has made a conscious choice to start a patient on long-term nitrofurantoin after assessing the risks and benefits, especially if they have been taking multiple short courses of it."
Cooper said the complaint had revealed that some practitioners were not aware of the potential for serious lung damage from long-term use of nitrofurantoin.
"It has shone a light on a very important issue and prompted necessary improvements and education to reduce the chances of a similar situation in future," she said.
In response to the tragedy, the providers involved had already made changes.
These include a request being made by the pharmacy to the Pharmacy Defence Association to request circulation of the appropriate information to all community pharmacists.
The spinal unit is creating an information document to be shared via the Royal New Zealand College of General Practitioners (RNZCGP).
The medical centre has conducted an audit of all patients prescribed this medication for monitoring and to ensure the side effects are reiterated to them.