An elderly patient has died from a skin-eating condition after being prescribed medicine she was allergic to, despite wearing a MedicAlert bracelet.
Health and Disability Commissioner Anthony Hill has released a report into the treatment of an 80-year-old woman who developed painful lesions, burning blisters and whose skin peeled off after she was given a medication she was registered as being allergic to in a Canterbury hospital.
The woman had been given the antibiotic trimethoprim by nurses after developing a suspected urinary tract infection while recovering from surgery in 2013.
She had been wearing a MedicAlert bracelet specifying her allergy to the medicine.
Within 24 hours she was admitted to intensive care with a life-threatening skin condition and underwent surgery to remove her damaged skin and to dress her extensive lesions.
She died a few days after.
Mr Hill said both the nurse and the registrar at the hospital has missed multiple opportunities to check the allergy and had missed the bracelet.
During the investigation, the nurse told the commissioner the ward was incredibly busy and the staff were tired.
But Mr Hill said it was still the registrar's responsibility to ensure the woman was prescribed appropriate medication and that the nurse's actions were a "severe departure from accepted standards".
The DHB, nurse and registrar have all been ordered to make formal apologies to the woman's family and a review into the nurse's competency has been recommended.
The DHB has also been asked to review and change some of its policies around checking allergies and workloads for staff.