A young woman relapsed into psychosis and started thinking about suicide after a pharmacist gave her anti-depressants instead of anti-psychotic medicine.
The pharmacist, who admitted responsibility and apologised, has been found guilty of professional misconduct.
The Pharmaceutical Society fined him $1500 and levied costs of $5205.
The woman had schizophrenia
and was switching from one type of anti-psychotic to another.
Her 2001 case has just been made public by Health and Disability Commissioner Ron Paterson, who found the pharmacist, breached the patients' code of rights. He referred the case to his director of proceedings, who laid the charge before the society.
Mr Paterson removed all parties' names from his report.
He said that instead of giving the woman, then aged 18, the Seroquel prescribed by her psychiatrist, the pharmacist dispensed the similarly-named Serzone, an anti-depressant.
The error went undetected for more than a month, until the woman's mother returned for a repeat prescription.
A locum pharmacist told her the drug was out of stock, but later noticed a label belonging to the anti-psychotic medicine was attached to a packet of the anti-depressants.
He alerted a co-owner, also a pharmacist, who went to the patient's home and informed the family of the mistake.
Until August 2001 the patient, had been progressing well on Risperidone anti-psychotic medication, but because of side-effects including weight gain, her psychiatrist prescribed a progressive change-over to Seroquel.
The psychiatrist said in October 2001 that when the patient finally started on Seroquel, she had gone several weeks without anti-psychotic medication and her mental state had deteriorated.
"She then became psychotic, experiencing auditory hallucinations, disorder of thought form, anxiety, persecutory ideation [ideas] and also started expressing some suicidal ideation." Her prognosis was reasonable, but she was "feeling quite hopeless at present", the psychiatrist said.
Mr Paterson found the second co-owner also breached the code of rights.
Mr Paterson said it was not inappropriate that this pharmacist took a limited quantity of Seroquel to the family, but in advising that the patient take 400mg on the night he visited, rather than waiting until the psychiatrist had been contacted the next day, he did not provide services with reasonable care and skill.
Mr Paterson said this pharmacist denied advising that the patient take 400mg that night.
