A former addict with liver cancer was in unbearable pain but failed to get the drugs he needed because of a communication breakdown.
In a report today, Mental Health Commissioner Kevin Allan said the Nelson Marlborough District Health Board must take responsibility for the "sub-optimal cooperation" among its staff providing care for the 64-year-old man over five weeks before his death in 2015.
Mr Allan's report followed a complaint by the man's wife, Mrs A, who said the family "watched as this poor man limped around like a wounded dog in unbearable pain. We'll never forget." She added the images it had left her with were "hard to deal with".
Mr Allan said her husband, Mr A, had been on an opioid substitution treatment programme under the DHB's addictions service for more than 25 years to help him reduce his drug dependence.
The saga began after he went to a hospital emergency department following a fall and was found to have suspected liver cancer. Mr A told the addictions service staff of his likely diagnosis, and also asked for his methadone to be increased.
A week later a hospital discharge summary detailed his medical condition, including his "possible poor prognosis and his wishes about end-of-life care".
Mr Allan said the addictions service staff did not receive a copy of that report, although it was also available on Mr A's electronic clinical record had they looked there.
Instead, addictions staff thwarted Mr A's attempts to get extra pain relief medication, believing this was "more about drug-seeking" than any pain he was in. Staff in the service added that Mr A's family doctor "does not believe [Mr A] will be in as much pain as he is claiming".
Mr A went back to hospital short of breath and in abdominal pain, and was admitted and treated with morphine. This was reported to the addictions service manager who replied that they "should be looking at reducing [the man's] methadone not increasing it".
Mr A was discharged from hospital with a prescription from a junior doctor for more methadone, but the doctor withdrew it when challenged by the addictions service staff. By this time Mr Allan said Mr A was in severe pain and deteriorating.
A scheduled MRI scan could not be completed because the pain he was in prevented Mr A from lying still.
That information was given to the addictions service manager, who had been away on leave, and who said it was the first indication he had had that Mr A could be needing methadone for clinical reasons rather than addiction.
About 15 days before Mr A died, an addictions service request form was filled in for Mr A, requesting more pain relief drugs and an increase in the doses, but it was declined.
Mr Allan said there was no information about who made the request, who completed the form, or the reason for its decline. He said the DHB had been asked but had no comment.
Mr A was transferred for palliative care and died shortly afterwards.
Mr Allan said he did not receive the pain relief he should have been able to access. He added there were missed opportunities for communication within the DHB about his condition and his pain-relief needs, and the DHB was responsible.
He recommended that the DHB apologise to the family and also:
- Develop a process for formal hand-over of addictions service clients when they move from outpatient to inpatient services and vice versa
- Conduct an audit to ensure all interactions with clients are recorded in addictions service record and or clinical records
- Review and revise job descriptions within the service to clarify roles
- Audit hospital discharge summaries for a month to see how many are sent to the relevant family doctors, as is required
- Run a refresher course for hospital staff on opioid substitution therapy and pain management for adults