The commissioner made seven recommendations to the Canterbury District Health Board (CDHB) including the development of a policy requiring the routine checking of MedicAlert bracelets.
Mrs Richardson was first given Trimethoprim, a bacteriostatic antibiotic, to treat a urinary tract infection in 2005 and 2006 where she developed shocking reactions, including blisters that caused her to lose 50 per cent of her skin.
In October 2013, Mrs Richardson tripped and fell at her home in Halswell, Christchurch. She broke her hip and had a pin inserted at Christchurch Hospital before being sent to Princess Margaret Hospital across the city to recuperate.
While recovering, she picked up a urinary tract infection.Hospital staff then administered Trimethoprim - despite the MedicAlert bracelet warnings.
Blisters "the size of my hands" covered her body and had to be "scrubbed off" in an operating theatre, Mr Richardson said.
Within days, she had lost 65 per cent of her skin.Terrified and weak, she died in her beloved husband's arms on November 30, 2013.
Throughout her ordeal, she had been wearing her MedicAlert bracelet, which stated "Allergy Trimethoprim".
Her medical notes had bright-coloured stickers highlighting her allergy."It's not so much that she died, it's the way she died that gets me," Mr Richardson said.
"It was an agonising and needless death that should never have happened.
"Today, the Health and Disability Commissioner concluded that in Mrs Richardson's case, the CDHB "failed to ensure that services were safe for patients and clinicians".
The report suggested CDHB develop a process where clinicians prescribing and administering medication were not interrupted or "otherwise exposed to factors associated with increased errors".
It recommended that both the Nursing Council and Medical Council consider reviews into the competence of both the nurse and doctor involved in giving Mrs Richardson the fatal drug dose without checking the warnings on her MedicAlert bracelet.
The Richardson family today welcomed the HDC's recommendations but were still angry about the negligence.
"While no amount of apologies will lessen our loss, the subsequent investigation has brought about changes which may prevent the possibility of this happening to someone else," a family statement given to NZME. News Service says.
"Tragically, the MedicAlert bracelet was on the same wrist as her hospital identification bracelet, but that did not prevent her death.
"We are also extremely upset that they either neglected to read, or chose to ignore, the Trimethoprim warnings on the bright orange stickers on each page of Eunice's hospital notes and drugs chart."
The CDHB said it would take up the routine checking of MedicAlert bracelets and install an electronic prescribing system which would set off an alert if a doctor attempted to prescribe a drug which was a listed allergy.
CDHB chief medical officer Dr Nigel Millar apologised for the "tragic events" that led to Mrs Richardson's death.
"We are sorry that our system failed to prevent the medication errors which had such devastating consequences for the patient and her family," he said.
"We acknowledge that these initiatives have come too late for Mrs Richardson and her family.
"However, we have changed how we care for patients and we are taking meaningful steps to prevent a similar event occurring in the future."
The MedicAlert Foundation is urging other district health boards to follow Canterbury's lead to put in place policies and connected IT systems to ensure the internationally recognised foundation service system was utilised as designed, to prevent avoidable harm, improve patient safety and respect health consumers' rights.
"When a MedicAlert Medical ID gets ignored, avoidable incidents happen, people get harmed and people die," chief executive, Murray Lord, said.
"The social impact on the effected person, their family, the wider community and Government can be massive and the hard-earned reputation of health providers and the careers of health practitioners can be ruined, all for the sake of a few seconds of good practice and due diligence."
Mr Lord said the public now have every good reason to expect government budget supported change at the highest levels.
Compliance requirements should be written in Government contracts with health providers, he said.
"If health providers are not prepared to take the initiative to connect to the MedicAlert system and solve this health consumer safety problem of their own accord, the Government needs to take decisive action and implement budget supported policy or regulation to make it happen."
• In October 2013, Mrs Richardson tripped and fell at her home in Halswell, Christchurch. She broke her hip and had a pin inserted at Christchurch Hospital.
• A few days later, she was sent to Princess Margaret Hospital across the city to recuperate. While recovering, she picked up a urinary tract infection. Hospital staff then administered Trimethoprim - despite the MedicAlert bracelet warnings.
• She was hospitalised for 15 days with toxic epidermal necrolysis - a rare, life- threatening skin condition caused by a reaction to the Trimethoprim.
• She died in her husband's arms on November 30, 2013. Throughout her ordeal, she had been wearing her MedicAlert bracelet.
• A raft of recommendations have been made by the Health and Disability Commissioner in a 37-page report released yesterday to prevent the "agonising and needless death" from happening again.
