DHB failures led to woman’s hepatitis relapse

Health and Disability Commissioner Morag McDowell today released a report finding Capital and Coast District Health Board (CCDHB) in breach of the Code of Health and Disability Services Consumers’ Rights (the Code) for failures in its care of a woman with lymphoma - cancer of the white blood cells.

The woman had a history of hepatitis B infection and required treatment with an antiretroviral medication (lamivudine) to prevent the hepatitis B recurring, as cancer treatments suppressed her immune system.

It was intended that the woman continue taking lamivudine for one year following her chemotherapy, but due to a number of systemic issues at CCDHB, the medication was stopped early. As a result, the woman suffered a recurrence of hepatitis B and required a liver transplant.

The Commissioner was critical that the information provided to the woman regarding the need to continue her lamivudine medication was inadequate. The information was only verbal, with no written reinforcement in pamphlets, clinic letters, or medication labelling, and no treatment summary was provided to the woman or her GP.

"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 Ms McDowell.

"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."

Ms McDowell recommended that CCDHB provide an update on the changes it has made as a result of this event, use an anonymised version of the report as a case study during education sessions, and provide a written apology to the woman.

The full report on case 19HDC01210 is available on the HDC website.