Clinical Director Backs Calls for Law Change After Tragic Death of Two-Month-Old Baby

In the wake of a devastating incident that led to the death of a two-month-old infant, medical professionals and pharmacists are calling for urgent changes to medication dispensing protocols. The tragedy has sparked a nationwide conversation about the safety of medication practices in community pharmacies and the need for systemic reforms to prevent such incidents in the future.

A Tragic Oversight

Bellamere Arwyn Duncan, a two-month-old baby, died at Starship Hospital on 19 July after allegedly being given an adult dosage of phosphate by a Manawatū pharmacy. A coroner’s preliminary opinion suggests that she died from phosphate toxicity, a condition that can lead to severe complications such as seizures, cardiac arrhythmia, and laryngospasms.

According to the baby’s parents, they were given instructions on how to dissolve one 500mg tablet of phosphate twice daily. They followed the directions and gave their daughter three bottles within 24 hours, totaling 1500mg — a massive overdose for an infant.

Medical Expert Backs Mandatory Two-Person Check

Dr. Jason Wister, Senior Medical Officer and Neonatal Intensive Care Unit (NICU) Clinical Director at the University of Otago, has called for a law change requiring two people to verify medication before it is dispensed. He emphasized that this is already standard practice in NICUs and could be implemented across all pharmacies with minimal effort.

Dr. Wister noted that phosphate is well known for its potential toxicity, especially in infants. He explained that a safe dose depends on the baby’s weight and that the overdose Bellamere received could have caused severe hypocalcemia, a condition where calcium levels drop dangerously low.

Pharmacist Voices Concerns Over Systemic Issues

Lynne Puklowski, Bellamere’s mother, described the tragedy as a “systemic failure.” She and her husband had taken the prescriptions to the pharmacy, only to be given the wrong dosage. Despite their concerns, they were not warned about the potential risk. Puklowski emphasized that the incident highlights the need for a more robust system to prevent such errors.

Lynne Puklowski said, “There needs to be something better in effect, rather than just relying on one person to make sure you're getting the right prescription, having at least a few eyes.”

Pharmacy Owner Responds to Allegations

The owner of the Manawatū pharmacy that dispensed the medication described the incident as a “tragedy” and expressed deep sorrow for the family. The pharmacy is currently conducting an internal investigation and working with external reviewers to understand how the error occurred.

“It is not appropriate to comment further at this stage,” the pharmacy owner said in a statement to RNZ.

Government and Health Agencies Under Scrutiny

The Ministry of Health and Pharmac have been called upon to review their policies on medication dispensing and ensure that adequate safeguards are in place for vulnerable groups such as infants and children. Pharmac has stated that it is always open to considering funding for medicines in an oral liquid form, as this can be more suitable for young children.

The incident has also prompted calls for a review of the current medication safety protocols in community pharmacies, with some experts suggesting that mandatory double-checks by trained professionals should be implemented to prevent similar tragedies in the future.

Next Steps

As the investigation continues, the focus remains on ensuring that such a tragedy never happens again. Families, healthcare professionals, and policymakers are all calling for systemic changes that prioritize the safety of the most vulnerable members of society.

This tragic incident is a stark reminder of the importance of medication safety and the need for continuous improvements in healthcare systems to protect the lives of infants and children.