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Decision No: 01/76D
Practitioner: Dr Edmond Freeland Walford
Charge Characteristics: Inappropriate prescribing
Inadequate follow-up care
Failure to refer
Additional Orders: None
Decision: 0176dfindings



The Director of Proceedings charged Dr Walford with professional misconduct. The particulars were as follows:

  1. He prescribed Codeine Linctus to his infant patient to be taken in 5 ml doses up to every 4 hours.

  2. When prescribing Codeine Linctus he failed to specify the strength of the medication to be dispensed.

  3. He failed to refer his patient to hospital immediately on diagnosing sedative/hypnotic poisoning.



The patient, a seven week old baby, was staying with her grandparents as she was suffering from a cough, vomiting and diarrhoea. The grandparents often had their grandchildren to stay when they were unwell as the island the children lived on, with their parents, had no resident doctor.

On 25 January 1999 the grandmother took the baby to see Dr Walford, (the baby's) family doctor). Dr Walford prescribed Codeine Linctus (cough mixture) and an antibiotic amoxycillin. The Codeine Linctus was to be taken in 5 ml sos toqh4. The strength of the mixture was not specified.

The baby was given two 5 ml doses of the cough mixture that day. The doses were given no more frequently than was prescribed. That evening the baby slept better, but at one stage appeared to stop breathing. The grandmother had to pick her up to get her breathing again. She was still coughing the following morning so she was given another dose of the cough mixture and a further 2.5 mls at lunch time as she seemed limp and did not look well.

The baby was taken back to Dr Walford by her mother and aunt on 26 January 1999. Dr Walford recorded that the baby was very sleepy. It was his opinion that she may have been drugged. It was alleged he told them that when the baby appeared to stop breathing she should have been taken to hospital and that if it happened again they should go straight to the hospital. Dr Walford disputed he was told the baby had stopped breathing.

Dr Walford phoned the pharmacist who dispensed the cough mixture and was informed the strength of the Codeine Linctus was 15 mg/5 mls which is the adult strength. Dr Walford diagnosed a codeine overdose and advised the baby's mother and aunt that the effects of the medicine would wear off in about four hours. He did not tell them to take her to hospital. He did not tell them to stop taking the medicine. He told them to reduce the dosage. He altered the dosage by writing on the bottle. He crossed out 5 ml and wrote 1.5 ml. He told the baby's mother and aunt to call him at any time and he gave them his telephone number.

The baby was given no more cough mixture but by about 5.30 pm she appeared no better. The baby's grandmother telephoned the number Dr Walford had provided but was unable to contact him. She then telephoned the hospital who told her to bring the baby in straight away. The baby was admitted to hospital on the evening of 26 January 1999. She was diagnosed with mild/moderate codeine overdose and viral gastro-enteritis. That night and over the next few days she had to be under constant surveillance.



Dr Walford pleaded guilty to the charge.

When the Tribunal considered the disputed facts it concluded that Dr Walford was told the baby had stopped breathing for a few seconds. However, the Tribunal was satisfied there was no question of Dr Walford having been deceptive. It seemed clear that the issue 'failed to register' with him and it should have.



The Tribunal considered the following issues influenced penalty in this case:

  • It is a medical practitioner's obligation to determine that a prescription is safe.
  • There are special dangers when prescribing for a child under three months of age.
  • Dr Walford was obliged to consider very carefully the appropriateness of prescribing codeine, and the dose for this patient.
  • Dr Walford on this occasion, for reasons that were unclear did not appreciate the danger.
  • When Dr Walford recognised that the patient was suffering from codeine overdose, he did not respond adequately.

However the Tribunal found while the errors were serious, and posed a significant risk to the patient, the Tribunal none-the-less recognised that they did not proceed from either indifference by Dr Walford to his patient, or failing to apply himself. In the circumstances, the Tribunal considered despite the errors being serious, this was not a case where a harsh or a deterrent penalty was called for.

The Tribunal ordered Dr Walford be censured and contribute $4,000 towards the costs and expenses of and incidental to the investigation, prosecution and hearing.