The Health and Disability Commissioner found "a series of missed opportunities through Wairarapa DHB's systems and staff" had failed "to catch what would become a fatal error".
The Health and Disability Commissioner found "a series of missed opportunities through Wairarapa DHB's systems and staff" had failed "to catch what would become a fatal error".
An 82-year-old man who suffered a stroke died after being given the wrong medication at Wairarapa Hospital, a report by the Health and Disability Commissioner has found.
When the man came into the emergency department, the house surgeon followed the stroke protocol, provided by another hospital, but was confused aboutwhich drug to use.
The protocol referred to using t-PA drugs, which the doctor correctly interpreted as two drugs: Tenecteplase, used for cardiac patients, and alteplase, used to dissolve blood clots in stroke patients, the report found.
Uncertain which drug to use, he called the hospital which provided the protocol and a miscommunication led to him administering tenecteplase.
The patient's condition appeared to improve but the next day he suffered a brain haemorrhage and died two days later.
Mistakes were made by staff at both hospitals and the Wairarapa District Health Board failed to provide services with reasonable care and skill, the report found.
The commissioner said the doctor's uncertainty resulted in a series of actions - all "small holes" in the provision of care - which lined up with disastrous results.
"There was a series of missed opportunities through Wairarapa DHB's systems and staff to catch what would become a fatal error."
A Wairarapa DHB representative said the board had acknowledged its shortcomings and put measures in place to ensure a similar event did not happen again.
"Wairarapa DHB has amended its stroke protocol to provide greater clarity on the management of thrombolysis in stroke cases, including the expectation that the treating DHB consultant be directly involved before any such treatment is given.
"In my view, those measures are appropriate."
The incident, which happened in 2011, has also been widely shared with other DHBs to prevent similar events.
Independent GP Dr David Maplesden, who gave clinical advice to the commissioner, said a lesson had been learned.
"While of little comfort to the bereaved family, it is important to note that appropriate actions have been undertaken by the DHB and these should enhance the safety of patients throughout the country who might be candidates for post-stroke thrombolysis in the future."
The other DHB involved said, "this has been a tragic event from which both DHBs have learned and implemented valuable lessons and shared those nationwide as a result".
