Clinical Director Backs Calls for Law Change After Tragedy of Two-Month-Old Baby Given Adult Dosage

Keywords: medication error, baby overdose, healthcare reform, phosphate toxicity, pharmacy error, neonatal care, law change, medical safety
Back to News List
Tuesday, 29 July 2025

Clinical Director Backs Calls for Law Change After Tragedy of Two-Month-Old Baby Given Adult Dosage

A heart-wrenching tragedy has sparked a nationwide call for change in medication dispensing protocols in New Zealand. The death of two-month-old Bellamere Arwyn Duncan, who allegedly received an adult dosage of phosphate from a Manawatū pharmacy, has drawn urgent attention to the need for stricter safeguards in the healthcare system.

Dr. Jason Wister, the Clinical Director of the Neonatal Intensive Care Unit (NICU) at Dunedin Hospital, has voiced strong support for a proposed law change that would require medications to be checked by two people before being dispensed. He emphasized that this practice is already standard in NICUs, and he believes it could be a "safe, low-risk, high-reward" solution to prevent similar incidents in the future.

The tragedy unfolded when Bellamere’s parents were given phosphate tablets at an adult dosage, which led to a massive overdose. The medication, prescribed for preterm infants to support bone health, was intended to be carefully measured based on the baby’s weight. However, the label on the medication instructed the parents to dissolve one 500mg tablet twice daily, which they followed as recommended. This resulted in Bellamere receiving a total of 1500mg in 24 hours — an amount far beyond what was safe for a two-month-old.

Dr. Wister explained that phosphate toxicity can lead to severe hypocalcemia, causing seizures, muscle stiffness, cardiac arrhythmia, and laryngospasms — all of which can be fatal in infants. The coroner's preliminary report suggests that Bellamere's death was a direct result of this overdose.

Lanny Wong, a pharmacist and member of the Pharmaceutical Society, echoed these concerns and highlighted the complexity of dispensing phosphate medications in community pharmacies. She emphasized the need for multiple checks to ensure accuracy, as even minor errors can have catastrophic consequences.

The parents of Bellamere, Tempest Puklowski and Tristan Duncan, are now advocating for systemic changes in the medication dispensing process. They described the incident as "something that can't really be overlooked" and stressed the importance of having multiple eyes on prescriptions rather than relying on a single person.

The Manawatū pharmacy that dispensed the medication has expressed deep sorrow and is conducting an internal investigation to determine how the error occurred. They have also pledged to cooperate with any external reviews to ensure that such a tragedy does not happen again.

Health officials and medical professionals across the country are now calling for a comprehensive review of medication dispensing protocols. They argue that the current system, which relies heavily on individual judgment, is not sufficient to prevent life-threatening errors.

As the nation mourns the loss of Bellamere, the incident serves as a stark reminder of the importance of safeguarding vulnerable patients. The proposed law changes, if implemented, could provide a critical layer of protection for infants and other patients who rely on precise medication dosing.

The tragedy has already prompted a nationwide conversation about healthcare safety and the need for systemic reform. As the investigation continues, the hope is that these changes will prevent future tragedies and ensure that every patient receives the correct medication at the right dosage.