Inadequate standard of care for increased oxycodone dosage - 21HDC02991

Deputy Health and Disability Commissioner Dr Vanessa Caldwell has found a GP breached the Code of Health and Disability Services Consumers’ Rights (the Code) in relation to an increased prescription of oxycodone.

The report concerns a woman who presented to the GP with significant chest pain. She had been taking oxycodone (an opioid pain reliever) for several years for chronic pain but had experienced increased pain due to her recently diagnosed lung cancer.

The women informed her GP that she had already increased her oxycodone dose herself and requested that her GP formally increase her dose to match this, as it had sufficiently relieved her pain.

The GP agreed to increase the dose of oxycodone. Sadly, two days later the woman passed away from oxycodone toxicity.

The case was referred to HDC by the Coroner.

Dr Caldwell found the GP breached the Code for failing to provide an appropriate standard of care when increasing the woman’s oxycodone dosage and the rate at which this was undertaken. The breach also applied to the inadequacy of documentation associated with the increased dosage.

Dr Caldwell said, "I would have expected documentation outlining the woman’s prior average daily dosage to have been recorded. This would have enabled the GP to review the risk of toxicity due to rapid up-titration and enabled a more accurate basis for calculating ongoing prescribing of the medication.

"Overall, I am concerned that the GP did not adequately account for the speed of increase and risks of accumulation."