Wrong prescription left teenager with 'suicidal thoughts'

Ron Paterson

The Health and Disability Commissioner has slammed the treatment given to a teenaged schizophrenia sufferer, which set back her recovery from mental illness significantly.

His report on the case claimed the 18-year-old woman slipped into psychosis, hallucinations and suicidal thoughts after a pharmacist mistakenly gave her anti-depressants instead of a new anti-psychotic medication.

The pharmacist, whose name has not been released, has been fined $1500 and made to pay $5206 in costs after the Pharmaceutical Society of New Zealand found him guilty of professional misconduct.

Health and Disability Commissioner Ron Paterson investigated the case and in his just-released report said the 18-year-old woman had previously been prescribed one type of anti-psychotic medication.

She had been making good progress on it but as it was causing side-effects, including weight gain and lactation, in August 2001 her psychiatrist prescribed her a different medication, called Seroquel.

Unfortunately, the pharmacist dispensed the similarly named anti-depressant Serzone instead and the mistake was not picked up until a month later when the woman's mother went to the pharmacy for a repeat prescription and a locum pharmacist noticed the difference.

In the meantime, the young woman became more frantic. "As a result of the dispensing error, (the woman's) psychotic symptoms returned and, day by day, she slipped more and more into psychosis," Mr Paterson reported.

She began to have voices in her head and her psychiatrist later told the commissioner that her mental state deteriorated and she started to express some suicidal ideas.

After the locum pharmacist picked up the error, another pharmacist, who was a co-owner of the pharmacy where the medicine was dispensed from, immediately went to the house of the woman's family and told them of the mistake, leaving some of the correct drug.

Mr Paterson found the first pharmacist had failed to provide services with reasonable skill and care.

The commissioner also found that the co-owner recommended the young woman should take a dose of the drug rather than wait to see her psychiatrist.

The pharmacist in question denied that finding.

A charge of professional misconduct against him was later withdrawn.

The young woman's psychiatrist told Mr Paterson the 18-year-old's prognosis was reasonable but the incident had "set her back significantly in her aims to resume a normal life.

"She has had some suicidal ideation and is feeling quite hopeless at present".

- NZPA