In 2011 The Australian Health Practitioners Registration Authority (AHPRA) determined that Dr John Gunzburg engaged in unprofessional conduct for his treatment of a patient. Dr Gunzburg is a General Practitioner with an interest in psychotherapy and addiction medicine.

The conduct of Dr Gunzburg had been referred to a Professional Standards Panel following a Coroner's inquest. His conduct related to treatment he had provided to a young female patient. At her first consultation with him and at her request Dr Gunzburg prescribed Lamotrigine. He later admitted it was a medication he had not previously prescribed. Dr Gunzburg prescribed her 100 mg per day, which was double the maximum initial dosage recommended in the literature. The patient developed a life-threatening hypersensitivity reaction to the medication and suffered a rash over most of her body, was bleeding from her eyes, nose and mouth and was then hospitalised. Whilst in hospital she developed an infection (probably enabled by the immune-suppressive effect of the corticosteroid treatment she had received for the hypersensitivity reaction) and she died within a few days. In the coronial inquest, Dr Gunzburg admitted that his initial prescription of Lamotrigine had been'a mistake'.

In addition to over-prescribing the medication, Dr Gunzburg was also found to have kept inadequate records of his attendances upon the patient.

AHPRA reprimanded Dr Gunzburg. It has required him to undertake education training in:

• importance of recording keeping and communication by doctors;
• safe prescribing practices and strategies to manage patient demands.

Although poor record keeping and mistakes in medication prescriptions are not uncommon, referrals to AHPRA for such conduct, are reasonably rare. It was sadly the tragic death of the patient, and the deep concern of her parents regarding the care provided, that meant this matter was not overlooked. It is hoped that the investigation and findings teach not only Dr Gunzburg, but other doctors, valuable lessons from the tragic death of this patient.

Andrea Tsalamandris of our office assisted the patient's family at the Coroner's inquest.