Inquest: GP criticised over phone scripts without review

Doctor on the phone

A coroner has criticised a GP for ‘sub-optimal’ treatment of a woman who died from respiratory failure

ACT woman Lesley Kaye Hasleby was 61 years old when she died on 13 September 2011 from respiratory failure consistent with end-stage chronic obstructive airways disorder.

At the time of her death, Ms Hasleby was a ‘vulnerable’ woman – with numerous chronic health complaints including liver disease, peripheral neuropathy, depression, alcohol dependence and chronic obstructive airways disease (COAD), explained ACT Chief Coroner Lorraine Walker.

She was alcohol dependent, a heavy smoker and suffered increasingly impaired mobility.

Ms Hasleby had been treated regularly by her GP since 1988.

During that time she had been prescribed dothiepin, oxazepam, Panadeine Forte for arthritis and peripheral neuropathy, and Ventolin and Seretide puffers for respiratory disease.

Whilst the GP had seen the Ms Hasleby on many occasions, the Coroner found her notes were often scanty and she regularly provided prescriptions upon a telephone request and without review.

In June 2011, a few months prior to Ms Hasleby’s death, a blood test had been taken that indicated hypoxia.

Despite this finding—which expert witness Dr Marcella Cox told the inquest warranted a review of Ms Hasleby within a few days—the GP did not seek to review the patient, saying she was “not surprised” by the results and noting that the patient was at times reluctant to accept advice.

The next time she spoke to Ms Hasleby was when she provided further prescriptions by telephone to her on 12 September 2011.

“These were issued by [the GP] without review,” Ms Walker found.

The practitioner continued to prescribe dothiepin and oxazepam to the patient, “each of which could cause respiratory depression against a background of respiratory decline without in-person review”, found Ms Walker.

She had “prescribed a potent cocktail of central nervous system depressant medications for a very long time. This continued in the period proximate to Ms Hasleby’s death by telephone without adequate review in the presence of cogent evidence of respiratory deterioration,” the Coroner found.

To this extent, the opportunity was lost to intervene in the patient’s deteriorating medical condition, Ms Walker said.

In her defence, the GP noted that she had sought to reduce Ms Hasleby’s reliance on these drugs over the years, particularly oxazepam, but that the patient was resistant.

Coroner Walker said the drug regime prescribed for Ms Hasleby was contraindicated regarding her conditions, particularly COAD.

She also noted that the GP’s failure to insist on a personal review in light of worsening hypoxia was “inappropriate”.

However it was not established that the lack of adequate medical intervention contributed to Ms Hasleby’s death.

The Coroner found the GP’s treatment was ‘sub-optimal’ but also noted that Ms Hasleby was a “difficult patient who failed to act in her own best interests”.

She considered it unlikely that the GP would replicate the same errors in the future.

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