The whānau of Brian Fryer complained to the Health and Disability Commissioner about a mistake made by Countdown Okara Park's supermarket pharmacy.
A grieving Whangārei family say they cannot accept the Health and Disability Commissioner’s recently released findings that their beloved dad died from a heart attack.
They say the report overlooks what they believe is the true cause of their father’s death: a pharmacy error that set off a chain of events that ultimately proved fatal.
The family complained to the HDC about the pharmacy error and issues with the care provided by Whangārei Hospital. They want his cause of death changed from heart attack to prednisone overdose.
In response to the Northern Advocate’s recent inquiries, the Health and Disability Commissioner (HDC) said it would review its decision, given the family’s concerns.
The 2022 error by Whangārei’s Okara Park Countdown (now Woolworths) Supermarket Pharmacy followed similar mistakes in 2019 at Woolworths/Countdown Pharmacy at Bayfair, Tauranga, but in which no one died.
Brian “George Fryer, 63, a father of four and grandfather to 16, died at Whangārei Hospital on November 21, 2022, after a heart attack.
On the morning of November 20, George – who’d already been up and taken that day’s medications – woke his wife Terangi in distress, struggling to breathe and making a sound she recognised as fluid in his stomach. Terrified, she drove him straight to Whangārei Hospital, desperate for help, and ran in twice before anyone came.
During that time, George became unconscious in the car, Terangi said, and was later assessed in the resuscitation room as having had a heart attack.
Terangi said she repeatedly told staff she believed George’s condition was due to prednisone and that they needed to counteract it.
“I told them I was with him for 31 years, I know my husband, this isn’t right, and it’s from that prednisone.”
It had been prescribed to George on September 20 that year for giant cell arteritis illness. The side effects were almost immediate, the family said.
“He was bright red,” Terangi said. His face and body were swollen with fluid, his torso blotched with rashes, and his weight climbed rapidly despite a lifetime of staying between 55 and 65kg.
“He’s never, ever been that big,” she said.
His breathing deteriorated so dramatically that he sought help twice, but each time, specialists sent him home, assuring him the steroid treatment and dosage were appropriate, Terangi said.
What the family didn’t know was that for at least nine days – possibly weeks more – George had been unknowingly taking quadruple the prescribed dose.
Ruby said the mistake only came to light after George died. When she opened the bottle that had been dispensed nine days earlier, she immediately noticed the tablets had a 20 stamped on them.
Fearing that meant the wrong strength, she and her mother went to the Okara Park Countdown supermarket Pharmacy on February 16, 2023. The manager confirmed the error and apologised. He immediately informed the Pharmacy Defence Association, the pharmacy directors, the Countdown Pharmacy support office, and held a team meeting.
The family believe earlier bottles may also have been incorrectly filled. They claim the manager told Ruby and Terangi he could not understand how the mistake happened, given the counting process and that the 5mg pills would have been white, not bright pink.
George – a tradesman with an eye for detail – would almost certainly have noticed if white pills suddenly switched to fluorescent pink ones. However, there was no way to check, as those bottles had long been discarded.
Taking what he thought were 10 5mg tablets each morning, George was likely swallowing 200mg daily for the first two days. He then reduced his dosage as instructed by his doctor, but because of the dispensing error, he was likely to still be taking four times too much – potentially up to 160mg daily.
This happened because the pharmacy had issued 20mg tablets instead of the prescribed 5mg tablets, despite the label correctly stating 5mg for his prescription.
The family waited nearly three years for the HDC report, expecting a full, boots-on-the-ground investigation; but have instead discovered it relied only on written submissions – seeking responses to the family’s complaints from medical professionals.
For example, submissions from Health NZ Te Whatu Ora Te Tai Tokerau sought to assure the whānau that prednisone does not cause an acute overdose illness and therefore was not a possible cause for George having a cardiac arrest.
The Fryers, however, point to numerous medical articles online that say otherwise. They felt they never stood a chance of being believed, and in their opinion, the report was “essentially just a cover-up”.
Daughter Ruby said she simply wants justice for her dad – that she and her family feel aggrieved, unheard and dismissed. They feel someone should be held to account. The experience has left them distrustful of New Zealand’s health system.
The report’s author, Deputy Health and Disability Commissioner Dr Vanessa Caldwell, accepted the pharmacy’s explanation that no individual staff member was at fault; the error arose from a failure to check the item before bagging, and the pharmacy has since taken steps to prevent a recurrence.
Contacted by the Advocate, the pharmacy manager echoed his earlier apologies.
He confirmed he had been working out his notice at the time and has since moved to another local pharmacy.
To her shock, Terangi recently encountered him while picking up a prescription from that store.
“I just went home and cried,” she said. The family believed he should personally be held accountable to some degree.
The HDC report did not apportion blame to any staff member and found no further action was necessary; Caldwell was satisfied with the pharmacy’s new safeguards.
“As we have not received any further complaints regarding dispensing errors since these events, I consider that the process changes have improved the safety of their dispensing practices,” she said.
The family’s complaints about George’s hospital care were also dismissed by Caldwell, who found it was “appropriate and responsive” to his needs.
Caldwell suggested the family were likely “overwhelmed” by the amount of information presented in a short time. However, she was pleased to see the hospital had reflected on this aspect of whānau support and had offered to hold a hui with Takawaenga support. The family claimed this was the first and only time they had heard of it.
Rather than being “overwhelmed” with information from the hospital, the family say there was a lack of it.
“We didn’t know what they were doing,” Ruby said.
Caldwell apologised for the years-long delay in producing the report, citing an unprecedented rise in complaints.
The decision, issued on October 10 last year without notification to the family, sat unseen in Terangi’s inbox until December.
“When Mum read the email, she just broke down and called us in tears,” daughter Ruby said.
They were critical that the pharmacy wasn’t asked to hand over video footage to identify a specific staff member responsible for the error and that no interviews were undertaken.
They want to warn the public to be more vigilant in checking pharmacy-dispensed medications.
The HDC noted its jurisdiction did not include determining the cause of death, which is a role for the coroner.
Head of Woolworths Pharmacy, Jeremy Armes, said the company’s thoughts were with the family. He understood the need for answers and closure.
Armes said the company had complied fully with the investigation and implemented all recommended procedure changes across its network of 48 pharmacies.
Earlier, Armes had told the HDC the company was planning to use the error as an anonymised case study at a training conference later this year to reinforce the importance of staff following standard operating procedures. Those updated procedures included the importance of a dispenser leaving the stock bottle next to the prescription so the pharmacist could check the dispensed medicine against the bottle and the prescription.
Sarah Curtis is a news reporter for the Northern Advocate, focusing on a wide range of issues. She has nearly 20 years’ experience in journalism, most of which she spent court reporting in Gisborne and on the East Coast.