A DHB has been criticised by the Health and Disability Commissioner after a man died from being given an antibiotic for a sore toe.
(File image) Photo: 123RF
The man went to Hutt Valley Hospital by ambulance, after taking flucloxacillin tablets, an antibiotic used to treat bacterial infections.
He had itchy skin, shortness of breath and then collapsed.
He was soon discharged with a possible allergy to the antibiotic, but this was not recorded in any database and the level of detail provided to the man was unclear.
Three weeks later, the man was on holiday when he arrived at another hospital with a sore toe.
Staff asked if he had any allergies, and he said he did not.
There was no alert on the national medical warning system of the man having any allergies.
Staff at that hospital gave him flucloxacillin through IV fluid, but he died of anaphylactic shock soon afterwards.
Deputy Health and Disability Commissioner Vanessa Caldwell said his home district health board in Hutt Valley had an inadequate system for ensuring that allergies were recorded and flagged in the national medical warning system.
It also had inadequate communication with the man's usual GP.
The warning system is linked to a patient's NHI number and is designed to warn health services of any known risks that may be relevant to someone's medical care.
Dr Caldwell said this showed weaknesses in the current system.
"Without doubt issues with the national system contributed to these events, I nonetheless consider it vital for individual medical centres and DHBs to have their own adequate systems and processes in place for drug and medication allergies, to ensure that staff are supported adequately in their decision-making and reporting requirements.''