Coroner stresses need for complete discharge summaries

A Victorian coroner has stressed the importance of discharge summaries ‘with all relevant information’ following the death of a 47-year-old woman due to mixed drug toxicity.
 
In findings published last month, the coroner recorded that the patient’s GP had not been supplied with details of a cross-titration process after a psychiatrist introduced an alternative medication regime while the patient was in a private Melbourne hospital.
 
According to the report, the psychiatrist initiated a regime gradually replacing a venlafaxine prescription with duloxetine, and a diazepam prescription with oxazepam after diagnosing the patient with persistent depressive disorder and alcohol use disorder.
 
The woman, who had asthma, chronic obstructive pulmonary disease, chronic liver disease, high cholesterol, hypertension, Wernicke encephalopathy, anxiety and depression, as well as a history of alcohol abuse and illicit drug use, attended the hospital for treatment of a broken hip in October 2021.
 
While at the hospital, she also had a psychiatric assessment leading to the medication changes.
 
After being discharged in November 2021, the 47-year-old had two telehealth appointments with her GP.
 
The coroner notes that a comprehensive medication list was provided and explained to the patient by the hospital pharmacist, with a copy made for the GP, while the hospital also stated that a discharge summary was faxed to the GP.
 
However, the GP reported receiving neither the discharge summary from the hospital nor a medication list from the patient’s pharmacy.
 
After checking SafeScript and consulting with the patient, the GP prescribed medications including tapentadol, oxycodone, mirtazapine, oxazepam, temazepam, venlafaxine and duloxetine.
 
According to the report, the cross-titration process for the new medication regime ‘was clearly explained to [the patient] before her discharge from hospital but it was not recorded in the discharge summary, nor communicated to her GP’.
 
The woman died on 26 December after calling an emergency doctor service on Christmas Day complaining of headache and nausea.
 
A forensic pathologist recorded the cause of death as mixed drug toxicity (venlafaxine, duloxetine, mirtazapine, oxycodone, tapentadol, benzodiazepines), with the coroner describing it as ‘the unintended consequence of her deliberate consumption of prescription medication’.
 
The pathologist noted toxic levels of venlafaxine and duloxetine.
 
In response, the coroner recommended the hospital ‘review its procedures and processes’ for formulating and communicating discharge summaries to GPs, which he said should include ‘all relevant information’ including medication requirements for mental health treatment.
 
These should be ‘promptly communicated’ to the patient’s GP, he wrote.
 
While not commenting on the specific circumstances of the report, Dr Michael Tam, who sits on the RACGP Expert Committee – Quality Care, said it is a reminder of the importance of clear communication following a patient leaving hospital.
 
‘People can get very fixed on this notion of a discharge summary,’ he told newsGP.
 
‘But we need to take a step back and understand what the concepts are here, what’s the purpose of it?
 
‘And perhaps the better way to consider it is that there needs to be some form of handover from the care team in the acute care facility to the person’s care team in the community, which would generally be the person’s regular GP.
 
‘The more complex and the higher risk a transition is from one facility or one sector to another sector, the more important it is that there is confirmation that the handover has actually occurred.’
 
He said even with complete details of a complex medication change included on a discharge summary, more active input may be required.
 
‘I would say that’s not enough, because the discharge summary in and of itself does not empower the person to actually make those changes,’ he said.
 
Dr Tam also said that while the handover of care involving a patient with complex illness from the emergency department to wards is usually very clear, it does not always work as smoothly when people leave hospitals.
 
‘For some reason, maybe for historical reasons, people often don’t view it the same way when people are discharged from a tertiary facility, and that in fact can be the riskiest time for the person,’ he said.
 
‘We try to emphasise it’s not just about discharge summaries, it’s really the whole process of the transfer of care.’
 
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