Bellamere Duncan died from an overdose. Photo / Supplied
By Sam Sherwood of RNZ
Warning: This story has details of the death of an infant.
A Neonatal Intensive Care Unit clinical director is supporting calls for a law change mandating medication be checked by two people before it is dispensed following the death of a 2-month-old baby after a pharmacy allegedly gave her an adult dosage of medication.
A member of the national executive of the Pharmaceutical Society agreed a change was needed, but said pharmacists need to be better resourced, adding the New Zealand pharmacy workforce “is in crisis”.
RNZ revealed Bellamere Arwyn Duncan died at Starship Hospital on July 19. The 2-month-old was allegedly given an adult dosage of phosphate by a Manawatū pharmacy. A coroner’s preliminary opinion is she died from phosphate toxicity.
The revelations have prompted the Ministry of Health and Health New Zealand to “urgently” review the incident. Medsafe visited the pharmacy to ensure it was safe to continue operating. The Pharmacy Council, which is also investigating, said it is “clear that an awful error has occurred”.
Bellamere’s parents are calling for a law change that would make it mandatory for medication to be checked by two people before it is dispensed.
University of Otago’s Dr Jason Wister, a senior medical officer neonatologist and Dunedin Hospital’s Neonatal Intensive Care Unit (Nicu) clinical director, told RNZ two people checking was already a policy in the Nicu.
“It seems like that would be a safe, low-risk, high-reward situation that would take very little time and effort to mandate.”
Wister said phosphate was well known as a potential for toxicity, especially in infants with “significant morbidity and mortality associated with it”.
The medication was prescribed for preterm infants for bone health and bone growth, he said, and a safe dose for a baby would depend on its weight.
The label on the medication Bellamere was given directed her parents to dissolve one 500mg tablet of phosphate twice daily in a glass of water.
Her parents gave her three bottles in 24 hours as had been recommended, totalling 1500mg.
Wister said the total amount she received would have resulted in a “massive overdose”, probably causing hypocalcemia, or low calcium.
“Phosphorus and calcium are in balance. As phosphorus increases, calcium decreases. An abrupt increase in phosphorus levels could have led to severe hypocalcemia, which can cause seizures, muscle stiffening, cardiac arrhythmia and laryngospasms.”
Pharmacist Lanny Wong, director of Mangawhai Pharmacy and a member of the national executive of the Pharmaceutical Society, told Checkpoint Bellamere’s death was “devastating” and she supported a “full, transparent investigation so the lesson can be learned from this tragedy”.
Wong said dispensing medicine such as phosphate was “not a routine process” for a community pharmacy.
“It is considered quite a complex process, [requiring] precise calculations, specialist knowledge and full attention.”
She said phosphate was given in a dispersible tablet.
“It does require the pharmacist to have full attention to do the calculation, and sometimes to cross check the dose against the weight of the baby.”
Wong said she had multiple pharmacists in her pharmacy, and had her prescriptions checked by another pharmacist if she was doing a “complex dispensing”.
She supported a mandated second check but said pharmacists needed better support.
“I think it needs to change, but to change it, we need to be well resourced. We need to be well funded, and we need to be supported. That’s what we need. But at the moment, we’re simply not supported - let’s just be frank, New Zealand pharmacy workforce is in crisis.”
Wong said New Zealand had 7.95 pharmacists for every 10,000 people compared to 9.3 in Australia, 9.1 in the United Kingdom and 9.6 in the US.
“So we are absolutely stretched. A lower density of pharmacist means there’s more pressure on people, longer working hours, reduced rate, and all the vital safety check has been compressed at the moment.
“And on top of that, pharmacies are acting like a shock absorber as well for the rest of the primary health system. For people that can’t see GP, they’re actually going to go see their pharmacist. And the Government wanting us to do more vaccinations and our jobs is becoming more complex, but we haven’t received the funding or the support to help us do this.”
On Monday, a police spokesperson confirmed to RNZ police were making inquiries on behalf of the Coroner.
Health Minister Simeon Brown told RNZ on Monday he raised the incident with the Director-General of Health as soon as he was made aware.
“She assured me that there would be an investigation undertaken by both the Ministry of Health and Health New Zealand. That investigation is under way.
“I am advised that this incident has led to Medsafe undertaking an urgent assessment of the pharmacy. A further investigation is being undertaken by the Pharmacy Council, and the death is also the subject of a Coroner’s inquest.”
Health agencies would provide information to the coroner as needed to support the inquest.
“It is important that the reviews are undertaken, and that the circumstances that led to this incident are understood. I expect that these investigations may propose recommendations, and that these will be reviewed once reports are complete.”
Labour health spokeswoman Ayesha Verrall told RNZ she was “horrified” to hear of Bellamere’s death.
“I will follow the outcome of the review closely to see if there are opportunities to stop this from happening again.”
A Health and Disability Commissioner (HDC) spokesperson said the Pharmacy Council had notified HDC of the incident as was required under the Health Practitioners Competence Assurance Act.
“HDC has referred this complaint back to the Pharmacy Council to manage as we consider they are best placed to address the issues raised.”
The Pharmacy Council said it was unable to comment further when asked by RNZ on Monday whether it supported calls for a law change.
“Our inquiry and investigation processes are currently under way and, until these are complete, we cannot provide any further details. At the end of the process, we will make any recommended changes to ensure as best as possible an event like this does not happen again.”
Pharmac’s director equity and engagement, Dr Nicola Ngawati told RNZ medicine doses for children were generally worked out based on the child’s weight.
“And so many formulations for children are oral liquids to allow for accurate dosing. These oral liquids may also be more suitable for certain adults, for example, people who are unable to swallow tablets.
“Whether or not a medicine is manufactured in an oral liquid formulation is a commercial decision for pharmaceutical companies.”
Pharmac was always happy to consider funding medicines in an oral liquid form if suitable, Ngawati said.
While in hospital, Bellamere’s mother, Tempest Puklowski, gave Bellamere Vitamin D drops. Nurses administered her phosphate.
When they left hospital, they were given Vitamin D in a little bottle, and a prescription for iron and Vitamin D.
The next day, Bellamere’s father, Tristan Duncan, went to a Manawatū pharmacy with the prescriptions. He was given the iron, but said the pharmacy refused to give the Vitamin D as the staff thought the dosage was “too high for her age and her weight”.
The staff said they would call the neonatal unit and follow up.
A few days later, Puklowski received a call from the unit to organise a home care visit. During the call, she was asked if she had any concerns, and Puklowski asked if the unithad been contacted about the Vitamin D. The staff had not, and said they would follow up and rewrite the prescription with a prescription for phosphate.
A day after the phone call, on July 2, Duncan went to the pharmacy to collect the medication and came home with just the phosphate.
That evening, they gave Bellamere her first dose of the medicine in her formula water. They would give her three bottles in 24 hours, as was recommended.
The couple noticed in that period that her eating was off, and thought she was “extra gassy”, Puklowski said.
“She was still feeding fine. She just wasn’t maybe going through a whole bottle compared to what she was,” she recalled.
The day after she got her first dosage, Bellamere suddenly stopped breathing.
She was taken to hospital and rushed to the emergency department. Once she was stabilised, she was taken to the neonatal unit where she stayed overnight before she was flown to Starship.
The couple took a bottle of the medicine with them to Starship and Puklowski gave it to the staff, who saw that they had been given an adult dose. The staff requested the original prescription, which had been written with the correct dosage, but somehow the pharmacy had given the wrong dosage, Puklowski said.
“I keep thinking about how much she ended up having, and it just makes me feel sick.”
Tragically, Bellamere died at Starship on July 19.
The couple are adamant they want changes to the system for giving out medication.
“It’s the sort of thing that can’t really be overlooked,” Puklowski said.
“There needs to be something better in effect, rather than just relying on one person to make sure you’re getting the right prescription, having at least a few eyes.”
The owner of the Manawatū pharmacy that dispensed the medication said the baby’s death was “a tragedy”.
“Our sympathy is with the family and whānau. This is a very difficult time.
“We are looking into what has happened to try to understand how this took place. There will also be external reviews, which we will work with.”
RNZ asked the owner how the medication was given at the wrong dosage, whether they disputed the allegations, when the pharmacy became aware the wrong dosage had been given, and what confidence people could have about other medication received from the pharmacy.
The owner said the pharmacy was “devastated about what has happened and are investigating to find out how this occurred”.
“It is not appropriate to comment further at this stage.”