A two-month-old baby died after receiving more than 13 times the prescribed dose of phosphate. Photo / Supplied
By Sam Sherwood of RNZ
The death of a 2-month-old baby from being given medication that was more than 13 times the prescribed dose is a “symptom of a much deeper, systemic issue,” a Pharmaceutical Society national executive member says.
RNZ earlier revealed Bellamere Arwyn Duncan died at Starship Hospital on July 19.
A Manawatū pharmacy dispensed an adult dosage of phosphate to the 2-month-old’s parents. A provisional post mortem report said she died from phosphate toxicity.
The revelations have prompted the Ministry of Health and Health New Zealand to “urgently” undertake a joint review into the incident with MedSafe visiting the pharmacy to ensure it was safe to continue operating.
The Pharmacy Council, which is also investigating, said it was “clear that an awful error has occurred”.
On Friday, the owner of the pharmacy emailed Bellamere’s parents and told them an intern pharmacist misread the prescribed dosage of medication.
Afterwards, a trainee technician, who was handling a phosphate product for the first time, did not notice the dosage error.
Then a registered pharmacist who carried out the final check did not pick up that the prescription was for an infant and that it was new medication.
The intern pharmacist has since been suspended, and the registered pharmacist has resigned.
Lanny Wong, a pharmacist, director of Mangawhai Pharmacy and a member of the national executive of the Pharmaceutical Society, told RNZ on Tuesday Bellamere’s death was “not simply a one-off mistake”.
“It’s a symptom of a much deeper, systemic issue. The current model prioritises volume over value, this incentivises speed at the expense of safety.
“For years, community pharmacies have grappled with operating under this fundamentally flawed funding system, marked by chronic underinvestment and relentless workload pressures.
“Skilled staff are increasingly difficult to retain, and experienced pharmacists are burning out or leaving the profession altogether. The very people relied upon to be the final checkpoint before a medicine reaches a patient are now overstretched, under-resourced, and unsupported.”
Wong said in healthcare there were multiple layers of safeguards that were meant to save an error from happening.
“But when there are gaps in every layer, caused by workload pressures, fatigue, underinvestment or broken systems and those gaps align, the error breaks through.”
Pharmacists were being asked to interpret complex prescriptions, perform clinical calculations, and provide personalised counselling, often while working under intense pressure and tight deadlines, she said.
“In Bellamere’s case, it appears the pharmacist had to calculate a specialised paediatric dose and explain a precise paediatric-dosing schedule to the whānau.
“This is work that requires expertise, care, and time, and yet the pharmacy was reimbursed less than the cost of a cup of coffee. That’s not just unsustainable. It’s unsafe.”
She said Bellamere’s death “must be a turning point”.
“It’s not just about fixing one pharmacy or one process, it’s about fixing the system around pharmacy.
“That means investing in safety, funding time to think, check and counsel, and designing a workforce strategy that ensures every community has access to skilled, supported pharmacists.”
In their email to Bellamere’s parents the owner of the Manawatū Pharmacy included a summary of what happened.
The owner said the pharmacy’s standard dispensing process involved intern pharmacists entering each prescription into the dispensary computer. The pharmacy used a dispensing system called Toniq.
A technician would then use the information in Toniq and the prescription to identify the medication and put the correct amounts in containers. The labels were then printed out and placed in a basket with the original prescription and the medication. A registered pharmacist would then check the prescription, the labels and the medication itself before it was given to the patient.
The owner said the pharmacy received the prescription by email on July 1 from Palmerston North Hospital.
The prescription was entered into Toniq by an intern pharmacist.
“This person unfortunately misread the prescribed dosage and entered the prescription dose as ‘1 tablet twice daily’ rather than ‘1.2 mmol twice daily’,” the owner said.
The Toniq system then generated an original label for the prescription.
“This includes a warning label with the patient’s age, if they are under 18 years old, and if the patient has not been prescribed the medication before.
“The second warning prompts the checking pharmacist to counsel (speak with) the patient or their caregiver about how to take the medication.”
The product was supplied in tubes of 20 tablets. The trainee technician printed out three further labels. They were to be placed on the three tubes that were being dispensed.
“This was the trainee technician’s first time handling a phosphate product. She was also unfamiliar with the mmol dosage. She did not notice the dosage error as a result.
“She put the original prescription, labels and the medication in a basket on the dispensing bench for the registered pharmacist to check.
“Unfortunately, the original label and the warning label was not kept with other items.”
The registered pharmacist who carried out the final check did not pick up that the medication was for an infant, the owner said.
“In addition, it was not identified that this was a new medication. The fact that the warning label was not retained contributed to this error.”
The owner said the intern pharmacist had been suspended by the Pharmacy Council. The registered pharmacist had taken leave and then resigned.
“This person does not intend to return to work in the immediate future,” the owner said.
The pharmacy was “urgently re-evaluating our dispensing and checking protocols and reinforcing safety checks at every stage”.
“We are actively recruiting additional staff to help manage our workloads. In addition, we are engaging an independent pharmacist from outside the Manawatū region to conduct a full review of our dispensing procedures and provide further guidance on system improvements.”
The owner said the pharmacy was “fully co-operating” with investigations being carried out by MedSafe, the Pharmacy Council and the police on behalf of the coroner.
The owner signed off the email with “heartfelt apologies and regret”.
Bellamere’s parents Tempest Puklowski and Tristan Duncan said after reading the email they did not blame the intern pharmacist for what happened.
“My first initial reaction after reading it was I felt really bad for the intern,” Puklowski said.
“I don’t blame him for the mistakes. I blame whoever was meant to be looking over his shoulder, whoever put him in that responsibility and just left him to it.”
Puklowski said it should have been picked up that the medication was for a baby.
“It just seems like there’s something lacking there that could have avoided it being missed or messed up,” she said.
Duncan said the system “needs to be better”.
Puklowski said she remained “frustrated and angry” about her daughter’s death.
“It’s just an endless sort of questioning of how and where it went wrong, to the point of, yeah, how could it have been avoided?
“Obviously, those questions don’t do much now, which then brings on the sadness of just knowing that she could still be here if these things were pulled up on initially, if maybe the intern wasn’t left just to do the job by themselves.
“Or if you know something else is put in place, we would’ve never even gotten it and then we wouldn’t be beating ourselves up for giving it to her.”
Duncan said the past two weeks since Bellamere’s death had been “really hard”.
“Just empty is the only word that really comes to mind,” he said.
“It’s unfair. Just stolen away by a singular document. That’s what it comes down to.”
Puklowski said the couple “don’t really know what to do with ourselves really”.
They were now waiting to see what happened with the multiple investigations that are under way.
“I want things to change,” Duncan said.
-RNZ