A Tragic Mistake and the Systemic Failures That Followed
A two-month-old baby, Bellamere Arwyn Duncan, died from a fatal overdose of phosphate medication. The incident has sparked widespread concern about safety protocols in pharmacies and the responsibilities of healthcare professionals involved in dispensing prescriptions. The tragedy has also left a grieving family questioning how such an error could have occurred.
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The sequence of events began when a prescription for phosphate was sent to a Manawatū pharmacy. An intern pharmacist entered the dosage into the dispensing system, but misread the prescription. Instead of entering “1.2 mmol twice daily,” the intern recorded “1 tablet twice daily.” This critical mistake went undetected by a trainee technician who had no prior experience with phosphate products and was unfamiliar with the mmol measurement. The technician then printed additional labels for the medication, which were placed in a basket for the final check by a registered pharmacist.
However, the registered pharmacist did not notice that the medication was intended for an infant or that it was a new prescription. The warning labels, which should have alerted them to the potential risk, were not properly retained or reviewed. As a result, the wrong dosage was dispensed to the parents, who later administered the medication to their daughter.
The Aftermath and Reactions from the Pharmacy
Following the incident, the Manawatū Pharmacy owner issued an email to the family, acknowledging the error and expressing deep regret. The pharmacy explained its standard process, which involves interns entering prescriptions into the Toniq system, followed by technicians preparing the medication and labels. A registered pharmacist then conducts a final check before the medication is given to the patient.
The owner admitted that the intern pharmacist had been suspended by the Pharmacy Council, while the registered pharmacist resigned after taking leave. The pharmacy is now reviewing its procedures and has hired an independent pharmacist to conduct a full review of its systems. They are also working to improve safety checks at every stage of the dispensing process.
Despite these steps, the family remains deeply affected by the loss of their daughter. Tempest Puklowski and Tristan Duncan, Bellamere’s parents, said they do not blame the intern pharmacist for the mistake. Instead, they believe the error stemmed from a lack of support and supervision during the process. “It just makes no sense that he was left to make up these prescriptions without having someone there with him making sure that he is filling out each one correctly,” Puklowski said.
The Medication and Its Consequences
Bellamere was given the phosphate medication at home, following the instructions on the label. She was told to dissolve one 500mg tablet twice daily in water. However, within days, she began showing signs of distress. Her eating habits changed, and she became unusually gassy. On the day after her first dose, she stopped breathing and was rushed to the hospital.
She was stabilized and transferred to Starship Hospital, where she remained until her death on 19 July. The family discovered that the pharmacy had dispensed an adult dosage of phosphate, which led to severe toxicity. Despite the correct prescription being available, the error in the dispensing process resulted in irreversible harm.
Calls for Change and Ongoing Investigations
The incident has prompted multiple investigations, including a joint review by the Ministry of Health and Health New Zealand, as well as assessments by Medsafe and the Pharmacy Council. The Pharmacy Council has stated that an “awful error” occurred and is conducting a thorough inquiry. Meanwhile, the coroner’s office is investigating the circumstances surrounding Bellamere’s death.
Health Minister Simeon Brown has confirmed that the incident has led to urgent reviews and that the findings will inform future actions. He emphasized the importance of understanding how such a tragic event could occur and ensuring that similar mistakes are prevented in the future.
For the family, the grief is overwhelming. “It’s unfair. Just stolen away by a singular document,” Duncan said. “We don’t really know what to do with ourselves.” They are waiting for the results of the ongoing investigations, hoping for meaningful changes to prevent such tragedies from happening again.
