Law Change Urged After Infant’s Death from Medication Error

A tragic incident involving the death of a two-month-old infant has ignited calls for a change in medication dispensing laws in New Zealand. On July 19, 2023, Bellamere Arwyn Duncan was reportedly given an adult dosage of phosphate by a pharmacy in Manawatū. This error led to her hospitalization at Starship Hospital, where she later succumbed to phosphate toxicity, according to a preliminary opinion from a coroner.

The incident has raised critical concerns about the current protocols in place for medication checks in pharmacies. A clinical director from a Neonatal Intensive Care Unit has expressed support for legislation requiring that two healthcare professionals verify medication before it is dispensed. This dual-check system aims to minimize the risk of similar tragedies in the future.

The urgency for reform is echoed by a member of the national executive of the Pharmaceutical Society, who acknowledged the necessity of such checks but highlighted the need for improved resources for pharmacists. They stated that the New Zealand pharmacy workforce is currently facing a crisis, which complicates the implementation of rigorous safety measures.

In the wake of this incident, health professionals are advocating for a thorough review of medication dispensing protocols to ensure that all patients, especially vulnerable infants, receive the highest standard of care.

As discussions around this legislation continue, the focus remains on preventing future medication errors and ensuring that every child receives safe and appropriate treatment.