A doctor has apologised to the family of a woman who died after being given the wrong drug.

Deputy Health and Disability Commissioner Kevin Allan said in a report released today the GP had breached the medical council's practices around prescribing drugs.

He has also asked the Medical Council of New Zealand to consider whether a review of the GP's competence is warranted after criticising his knowledge around what drugs were interchangeable.

The medical centre the woman attended has also been told to carrying out an audit of all patients who were given the same drug - zoledronic acid infusions - during 2018.


The woman, who suffered chronic renal disease and was receiving diuretics, visited her GP with her husband during 2016 complaining of chronic leg pain.

She had already been identified by the pain clinic as a suitable candidate for pamidronate and was waiting to start the trials. Pamidronate is given to treat some bone diseases and bone pain.

But because the patient was desperate for some immediate relief, the GP gave the woman a zoledronic acid infusion for pain relief, wrongly thinking that zoledronic acid and pamidronate were interchangeable. Zoledronic acid is used in primary care to treat osteoporosis.

The woman became increasingly unwell several days after having the infusion and she was eventually hospitalised. She died on the same day hospital blood tests showed she had acute renal failure.

Allan found the GP had failed to provide services to the woman with reasonable care and skill.

He had also breached the Medical Council of New Zealand's Good Prescribing Practice statement and criticised the doctor for not realising that zoledronic acid was not a suitable replacement for pamidronate.

A Medsafe data sheet for zoledronic acid states that it should not be used in patients with severe renal impairment because it can increase the risk of renal failure.

The medical centre was also found vicariously liable for the inadequate care provided by the GP.