Pharmacy Error Leads to Tragic Death of Two-Month-Old Baby

The death of two-month-old Bellamere Arwyn Duncan has sparked a nationwide investigation into a serious pharmacy error that resulted in her receiving an adult dosage of phosphate medication. The tragedy, which occurred on 19 July at Starship Hospital, has raised critical questions about the safety of medication dispensing processes and the need for systemic reform in the healthcare sector.

A Chain of Errors

A series of lapses occurred within the pharmacy's dispensing process. An intern pharmacist misread the prescribed dosage, entering '1 tablet twice daily' instead of the correct '1.2 mmol twice daily'. This error was not caught by a trainee technician, who was unfamiliar with the mmol dosage and phosphate products, and was also not flagged by the final checking pharmacist, who failed to recognize that the prescription was for an infant and involved new medication.

Consequences and Reactions

The intern pharmacist has since been suspended, while the registered pharmacist has resigned. Bellamere’s parents, Tempest Puklowski and Tristan Duncan, have expressed their devastation but have not blamed the intern pharmacist for their daughter's death. Instead, they have called for a law change that would mandate double-checking of all medications before dispensing.

Systemic Failures and Calls for Reform

The parents emphasized that the error was not solely the fault of the intern pharmacist but rather a result of inadequate oversight and support. They described the situation as a failure in the system that left the intern pharmacist without proper guidance.

The pharmacy has acknowledged the error and stated that it is re-evaluating its dispensing and checking protocols. Additional staff are being recruited, and an independent pharmacist is being brought in to review the dispensing procedures. The pharmacy is also cooperating fully with ongoing investigations by Medsafe, the Pharmacy Council, and the police on behalf of the coroner.

Investigations and Next Steps

The Ministry of Health and Health New Zealand have initiated a joint review, with Medsafe conducting an urgent assessment of the pharmacy’s safety. The Pharmacy Council has confirmed that immediate steps have been taken to prevent further harm while the investigation is ongoing. Health Minister Simeon Brown has assured the public that an investigation is underway and that the findings will inform the coroner’s inquest.

The parents remain in a state of grief and frustration, emphasizing that their daughter’s death was preventable. They are now waiting for the outcomes of the multiple investigations and are calling for significant changes in the medication dispensing process to prevent such tragedies in the future.

Conclusion

The tragic death of Bellamere Arwyn Duncan serves as a stark reminder of the importance of safety in healthcare. As the investigations continue, the calls for reform and the need for a more robust system of checks and balances in medication dispensing are growing louder.