A Tragic Mistake That Exposed a Systemic Failure

The death of two-month-old Bellamere Arwyn Duncan has sent shockwaves through New Zealand's healthcare system. The infant died on 19 July at Starship Hospital after being given a medication dose that was more than 13 times higher than what was prescribed. This tragic incident has now sparked a broader debate about the state of pharmacy practices in the country.

A System Under Pressure

Lanny Wong, a pharmacist and member of the national executive of the Pharmaceutical Society, has called the incident a 'symptom of a much deeper, systemic issue.' She highlights that the current model of funding for community pharmacies prioritizes volume over value, creating an environment where speed is prioritized over safety.

Wong explains that pharmacists are being asked to perform complex tasks—interpreting prescriptions, performing clinical calculations, and providing personalized counselling—often under intense pressure and with limited time. '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.'

A Series of Failures

According to the owner of the Manawatū Pharmacy, the error occurred due to a series of failures across multiple stages of the dispensing process. An intern pharmacist misread the prescribed dosage, a trainee technician failed to notice the mistake, and a registered pharmacist who conducted the final check did not recognize that the medication was for an infant or that it was a new medication.

The pharmacy owner described the incident as 'an awful error' and confirmed that the intern pharmacist had been suspended and the registered pharmacist had resigned. The pharmacy has since taken steps to re-evaluate its dispensing protocols and has engaged an independent pharmacist from outside the region to conduct a full review of its procedures.

A Call for Change

Bellamere's parents, Tempest Puklowski and Tristan Duncan, have expressed their anguish over their daughter's death. They do not blame the intern pharmacist but rather the system that placed him in a position where he was left to make critical decisions without adequate support.

'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. Duncan added that the system 'needs to be better' and that the tragedy could have been avoided with proper oversight and support.

A Turning Point

Lanny Wong has called for a complete overhaul of the pharmacy system, emphasizing the need for investment in safety, proper funding for pharmacists, and a workforce strategy that ensures every community has access to skilled, supported pharmacists. She said Bellamere's death 'must be a turning point' and that the focus should be on fixing the system, not just the individual pharmacy involved.

The Ministry of Health and Health New Zealand have also launched a joint review of the incident, with MedSafe visiting the pharmacy to ensure it is safe to continue operating. The Pharmacy Council is also investigating the matter, and the police are assisting with the coroner's investigation.

What Comes Next?

The pharmacy owner has apologized to Bellamere's family and is working to implement new safety checks and protocols. However, the family is left with the painful question of what could have been done differently to prevent the tragedy. As they wait for the results of the ongoing investigations, they are calling for a systemic change that ensures such a mistake can never happen again.

'It's unfair. Just stolen away by a singular document. That's what it comes down to,' said Duncan. Puklowski added that the couple 'don't really know what to do with themselves' and are waiting to see what happens with the multiple investigations that are under way.