A man died after multiple health professionals failed to ensure he fully understood the serious risks of taking an antibiotic for more than six months.
The man, who was a paraplegic, used intermittent self-catheterisation to control his lack of bladder control.
He dealt with ongoing urinary tract infections as a result and was prescribed the antibiotic nitrofurantoin by a specialist from a spinal unit at a district health board (now Health NZ Te Whatu Ora) in 2017.
The man’s treatment was the subject of a complaint to the Health and Disability Commissioner (HDC), which found several health practitioners failed to ensure he fully knew the risks of taking nitrofurantoin long-term.
According to MedSafe, taking nitrofurantoin for more than six months can lead to pulmonary toxicity (lung damage).
Because medication successfully treated the man’s symptoms, his GP and a urology registrar at another public hospital continued to prescribe it — without ensuring he understood the risks of use beyond six months, the HDC noted.
The pharmacy that dispensed the drugs also failed to advise him of the risks.
He ended up taking nitrofurantoin for 28 months over three years and was never warned about the risk of pulmonary disease.
“According to [the man’s wife], at no time was her husband aware of the risk of lung disease from using nitrofurantoin for over six months,” the report read.
“[His wife] told HDC that after having taken nitrofurantoin for about six to eight months, initially, her husband developed a mild and dry cough, but as they were not aware that this could be related to the nitrofurantoin, they did not raise any concerns about this at the time.”
In 2019, he died from complications of nitrofurantoin-related pulmonary toxicity.
“Consequently, he did not have the opportunity to make a fully informed decision about whether the potential benefits outweighed the risks of continuing to take the medication,” the report said.
Following his death, the man’s wife made a complaint to the HDC.
She said in her complaint: “Above all, I would like to prevent another avoidable death as a result of a lack of professional knowledge about the adverse effects of nitrofurantoin.”
Deputy Health and Disability Commissioner Carolyn Cooper found the health practitioners who were responsible for the man had “missed opportunities” to inform him of the drug’s side effects properly.
“Although I am very critical that none of the health service providers who cared for the man ensured that he understood the risks, I consider that no single individual or service was significantly more responsible,” Cooper said.
“All the healthcare providers who had a role in the prescribing and dispensing of nitrofurantoin to the man could have checked whether he was aware of the long-term risk at appropriate times, and it is concerning that this did not occur.”
One of the doctors said he was “devastated” to hear of the man’s death and apologised to his family.
“Any role I played in this process profoundly disappoints me. I feel a sense of responsibility for this and am immensely frustrated that my interaction with him wasn’t the small moment that was needed to alter his trajectory away from premature death.”
Cooper also noted that some practitioners who prescribe and dispense nitrofurantoin, including those who treated the man, were not aware of the lung damage risk.
“It has shone a light on a very important issue and prompted necessary improvements and education to reduce the chances of a similar situation in future,” she said.
Since the man’s death, the providers have all made “significant” changes and improvements to their process of prescribing nitrofurantoin.
The pharmacy requested that the Pharmacy Defence Association spread appropriate information about the medication to all community pharmacists.
The spinal unit also created an information document to be shared via the Royal New Zealand College of General Practitioners.
The medical centre audited all patients prescribed nitrofurantoin to monitor them and ensure they were reminded of the side effects.