A 96-year-old woman has been found to have died from being given high blood pressure medication by mistake at a rest home.

Deputy Health and Disability Commissioner Rose Wall says in a decision made public today that the woman's medical history included high blood pressure, but in early 2013, when she was given the medication in error, she did not have the condition.

A caregiver, Ms C, was distracted by another resident when conducting the morning medication round at the unnamed rest home.

The caregiver had organised medication to give to the 96-year-old Mrs A and some blood-pressure-lowering drugs for another resident. By mistake, she gave the blood-pressure-lowering drugs to Mrs A.


The caregiver quickly realised her error, but it was around an hour before she phoned at 9.12am to report the mistake to the on-call registered nurse, having completed the medication round first.

On the nurse's advice, the caregiver monitored Mrs A. In the absence of specific advice on what monitoring to do, every 20 minutes she asked the woman if she was all right, checked her breathing and touched her head to see if she had a temperature.

Just before 10am, the woman became unresponsive. The caregiver called the nurse, who referred her to an off-duty nurse for help. This nurse came to the rest home and found Mrs A semi-conscious.

An ambulance took Mrs A to hospital, where she later died.

Ms Wall says a coroner found the direct cause of death was sudden death following ingestion of medications used to treat high blood pressure.

The deputy commissioner found the caregiver and the on-call nurse had breached the code of patients' rights.

The caregiver breached the rest home's policy by allowing herself to be distracted while administering drugs and by not immediately notifying the senior caregiver, a nurse, the manager or a doctor.

Ms Wall said the nurse who was on call at the rest home -- while also working at another residential care facility -- had failed to give adequate monitoring instructions to the caregiver.

The deputy commissioner recommended the caregiver and the on-call nurse apologise to the woman's family and that the Nursing Council consider reviewing the on-call nurse's competence.