Insufficient clinical checking at a pharmacy was the primary cause of a dispensing error that led to the overdose and death of an eight-week-old infant last year, Medsafe has found.
The regulator today published its summary of findings as part of a broader system review into the July 2025 incident, in which a community pharmacy dispensed oral phosphate at a dose approximately 13 times higher than prescribed to an infant being treated for a phosphate deficiency.
The child - Bellamere Arwyn Duncan - was admitted to hospital and subsequently died.
Health NZ MidCentral also completed a Serious Adverse Event Review into Bellamere's death, which occurred in the month after her discharge from Palmerston North Hospital. Her parents are Tempest and Tristan Duncan.
"We recognise the grief and loss experienced by Bellamere's parents Tempest and Tristan and the wider whānau and we extend our deepest sympathies to them," said MidCentral chief medical officer Dr Claire Hardie.
The prescription, processed by an intern pharmacist, was for Phosphate Phebra effervescent tablets at a dose of 1.2 mmol twice daily.
Each tablet contained 16.1 mmol of phosphate — meaning the correct dose required dissolving one tablet in 16 mL of water, drawing up just 1.2 mL of the resulting solution, and discarding the rest. The prescribed dosage would have been safe.
However, the intern pharmacist generated a dispensing label with a incorrect dosage instructions, instead directing the caregiver to give the child one full tablet twice daily.
Medsafe concluded that the pharmacist who conducted the final check of the prescription failed to adequately assess its clinical appropriateness and accuracy.
Failure 'particularly significant'
It described this failure as "particularly significant given the age of the patient". The pharmacy was unable to demonstrate that the check met the required standard.
Contributing factors included failure to recognise that the prescribed dose required significant dilution before administration, absence of counselling to the caregiver at collection, and a busy pharmacy environment.
The MidCentral review found the tragedy involved multiple process failures spanning discharge planning, communication with the family, and community pharmacy practice.
The review included whānau, clinicians, Medsafe, and representation from the community pharmacy provider. Bellamere's family were interviewed early in the process to share their experience, and MidCentral continued to meet with them throughout.
Recommended actions from the review included updated guidance for managing metabolic bone disease in premature infants, stronger clinical documentation, improved discharge procedures in the Palmerston North Hospital neonatal unit, training on safe prescribing and administration of paediatric medications, and support for the national introduction of electronic prescribing for outpatients.
An action plan and monitoring programme was in place to implement the recommendations.
Medsafe called on pharmacists to exercise extra vigilance when dispensing hospital prescriptions for paediatric patients, to always verify a patient's age during clinical checks, and to ensure caregivers received clear verbal and written instructions — particularly for complex dosing regimens.
Ministry of Health chief medical officer Dr Joe Bourne said the incident had a "profound impact" on the family involved and the health professionals and organisations responsible for their care.
Medsafe conducted an inspection of the pharmacy following notification, which ruled out any immediate ongoing public safety risk.
Medsafe said it would continue working with Health NZ, the Pharmacy Council, and the broader pharmacy sector to strengthen safeguards and prevent similar events.
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