Eunice had an allergic reaction to a single dose of trimethoprim, and developed toxic epidermal
necrolysis, which caused her death.
The Hospital systems used to alert Health Practitioners of Eunice’s life threatening Allergy were
ignored.
Furthermore, Eunice’s MedicAlert® Service Supported Medical ID, which is internationally recognised
and clearly stated this allergy, was also ignored.
Prevention of Avoidable Harm is paramount and so too is respecting a Health Consumers Rights, while also acting in the best interests of the Health Consumer.
To prevent an incident such as this occurring again, please take heed of and act on the following information:
Coroners Statement (COR REF: CSU-20130CCH-000675)
In the Eunice Richardson case, the Coroner issued the following statement: [18] Pursuant to my obligations under S 57 (3) of the Act I draw to public attention the services provided by MedicAlert® Foundation and recommend that patients suffering from adverse reaction to drugs or suffering from allergies or other conditions which would benefit from early and clear advice as to treatment take advice from their health professional as to whether they would benefit from the
MedicAlert® service.
Heath and Disability Commissioner (Case 14HDC00157)
In this case, the Health and Disability Commissioner issued the following provisional recommendation:
147(b): Develop a policy requiring the routine checking of MedicAlert® bracelets.
149: In response to the HDC
provisional opinion, CDHB advised in relation to recommendation b): There is,
at present, no policy that specifically covers MedicAlert® bracelets, but it is a “standard source of clinical information”. CDHB advised
that it will take up this matter.
Implementing Policies for correct utilisation of the Foundation's Harm Prevention System
For development of Policies which are consistent with the design and intended use of the Foundation's Harm Prevention System (including all Medical ID’s), please refer to MedicAlert® National Health and Safety Protocols
Medical Alerting Portal
The Foundation's Harm Prevention System includes a vital Medical Alerting Allergies Register (amongst other features and registers), which again is accessible 24/7 through use of information engraved on the MedicAlert® Medical ID, or the Health Consumer NHI Number.
Health Providers can obtain direct Single sign-on (‘SSO’) access to the Foundation's Medical Alerting Portal for in-house use at the point of care, including ED Triage. Connected Health IT to maintain the Health Consumers vital information is also imperative, in the best interests of reliable Health Provider utilisation of the system, staff productivity and Health Consumer Safety.
For Health Provider organisations direct SSO access to the Foundation's Medical Alerting Portal is preferred. Once implemented, calling the MedicAlert® Emergency Hotline Number can be seen is an essential fail safe, in case of natural disasters, or when SSO access to the Portal is not immediately available at the point of care.
To discuss implementation and access to the Foundation's Medical Alerting Portal, please contact MedicAlert® at inquiry@MedicAlert.co.nz, or call the Foundation on 0800 840 111 and ask for the Foundations Business Development Manager.