Woman required liver transplant after DHB took her off medication early

Source: 1News

A woman suffered a hepatitis relapse and needed to have a liver transplant after “systemic issues” within the Coast and Capital DHB saw her prematurely taken off medication, the Health and Disability Commissioner has found. 

Medical staff walk along a hospital corridor

Due to undergoing cancer treatment for lymphoma, the woman, who also had a history of hepatitis B, needed to be on antiretroviral medication to prevent hepatitis from reoccurring. 

She was meant to be on the medication for a year post-cancer treatment but due to issues within the district health board, her medication was forced to stop early. 

It triggered a hepatitis B relapse and led to the woman requiring a liver transplant. 

In a report released by the Health and Disability Commission, the CCDHB was found in breach of their patient code. 

Commissioner Morag McDowell criticised the district health board for its inadequate information about the medicine provided to the woman. 

“There was no clear plan to ensure the woman stayed on lamivudine following chemotherapy. 

“As a consequence, her prescription for lamivudine was stopped too early and this went unnoticed resulting in her hepatitis B being reactivated.” 

She was only told verbally about her need to keep taking lamivudine, wasn’t given any supporting pamphlets, clinical notes or medication labelling. 

Her GP also wasn’t given a treatment summary. 

“The DHB lacked clarity about roles and responsibilities, and there was no formal protocol for preventing hepatitis B reactivation in patients undergoing immunosuppressive therapy,” said McDowell. 

McDowell’s recommendations to the CCDHB included having the district health board provide an update on changes made as a result of this incident and write an apology to the woman. 

It was also suggested that an anonymised version of the Health and Disability Commission’s report be used as a case study for education sessions. 

CCDHB Chief Medical Officer John Tait told 1 NEWS they have since carried out their own review into the incident, with a range of changes being carried out to prevent any further risk. 

"No harm to a patient under our care is acceptable. We take patient safety extremely seriously and acknowledge that we failed the patient and whanau in this instance." 

The district health board has since brought in changes including protocols around dealing with hepatitis B patients who have cancer as well as recommending that these patients are discussed with the infectious diseases team before they start chemotherapy. 

"The vast majority of our patients receive safe, timely and high quality service and we are continually looking at how we can improve the way we support and care for our patients," said Tait.  

Guidelines for the coordinated care of patients with a risk of hepatitis reactivating during and after cancer treatment have also been introduced.  

The CCDHB has also created an information pack around the risk of hepatitis B for patients along with information about treatments and reactiviations.