The devastating blistering skin reaction seen in a 74-year-old woman who died in Dunedin Hospital in 2008 was extremely rare, internal medicine specialist Dr Andrew Bowers says.
He was giving evidence yesterday at the inquest by southern regional coroner David Crerar into the death of Mosgiel woman Miriam Joy Kerr on October 9, 2008.
Dr Bowers said such a drug reaction was about a one-in-a-million occurrence.
Pathologist Dr Peter Fitzgerald, who conducted Mrs Kerr's postmortem, told the court he believed her death was due to toxic epidermal necrolysis (TEN) with associated bronchopneumonia and multiple organ failure.
(TEN is a condition in which the top layer of skin all over the body becomes detached from lower layers).
Dr Fitzgerald said his inquiries suggested there had only been four cases around the world of such reactions to drugs from the cefalosporin antibiotic family.
The court was told Mrs Kerr, who had complex health conditions, developed a rash while in a residential care facility after receiving two doses of the antibiotic Cefaclor, prescribed for a lung infection by general practitioner Dr Roy Morris (now in Australia).
The doses were administered on the evening of September 29 and morning of September 30, but no further doses were given after this because of the appearance of the rash.
In letters read by inquest officer Senior Constable Robert Murray, Dr Morris said Mrs Kerr had a past history of reaction to Augmentin (a penicillin-based antibiotic) and her Dunedin Hospital notes showed she had had Cefaclor previously without problems.
When her condition deteriorated, she was admitted to Dunedin Hospital on October 3.
In her evidence, Mrs Kerr's daughter, Lynette, told of her concern Augmentin and Amoxycilin had been administered to her mother in Dunedin Hospital during a July-August visit in 2008 despite staff being informed of her Augmentin allergy.
In his evidence, the clinical leader of Dunedin Hospital's internal medicine department, Dr Brendon Rae, said the concerns listed by Miss Kerr were valid.
That was "purely and simply a mistake", he said.
Miss Kerr said her mother had developed a rash during that hospital stay. She had asked if it could be noted as being a possible reaction to the antibiotic, considering her mother's history.
It was only later she had discovered her mother had received intravenous Augmentin and Amoxycilin.
What was upsetting was that although she had conversations about the rash with a number of Dunedin Hospital staff and the family knew she had an Augmentin allergy, "at no time we were informed of the truth".
The rash had cleared before Mrs Kerr went into residential care.
Mr Crerar ordered interim suppression of the details of Miss Kerr's concerns about the care provided at the residential facility, the name of the organisation involved and that of a nurse witness who had worked there.
He said this was to allow the organisation to respond to the issues raised.
Dr Rae, referring to Dunedin Hospital treatment, said the case illustrated what was called "confirmation". This happened when staff thought they knew what caused something and saw everything that happened subsequently as confirmation of that.
He suggested this had occurred when staff started thinking the rash could be related to Mrs Kerr's cutaneous lupus condition.
During cross-examination Dr Rae, responding to questions about differentiating between degrees of allergic response, said junior doctors were "fairly lax" about defining what they meant by an allergic reaction.
It was hoped a centralised electronic medication register would address many of the issues with medication errors, including being able to "flash through a warning" about known allergies.
Patients and the community believed hospitals were safe, but they were "far from safe", with about 10% of patients being harmed.
The most common harm related to the giving of drugs.
Drs Rae and Bowers both provided reports of their review of the case and responses to concerns raised by Mrs Kerr's family.
Under cross-examination Dr Bowers, who is also clinical leader of the Ministry of Health's safe medication management programme's electronic prescribing project at Dunedin Hospital, said the pilot was fully functional in internal medicine wards.
It was working so well it was hoped it would be funded to cover the whole of the hospital and, eventually, the rest of New Zealand.
At the end of the day's hearing, Mr Crerar advised he would reach a finding after he had received the additional submission from the residential care organisation.
