An intern pharmacist has been suspended by the Pharmacy Council following the death of a two-month-old baby who was allegedly given medication at an adult dosage.
Warning: This story details the death of an infant
RNZ earlier revealed Bellamere Arwyn Duncan died at Starship Hospital on July 19. The two-month-old was allegedly given an adult dosage of phosphate by a Manawatū pharmacy. A coroner’s preliminary opinion was that she died from phosphate toxicity.
The revelations prompted the Ministry of Health and Health New Zealand to “urgently” undertake a joint review into the incident with Medsafe visiting the pharmacy to ensure it was safe to continue operating.
The Pharmacy Council, which was also investigating, said it was “clear that an awful error has occurred”.
Bellamere’s parents were calling for a law change that would make it mandatory for medication to be checked by two people before it was dispensed.
A pharmacist who works at the Manawatū pharmacy had since been suspended by the Pharmacy Council and was not entitled to practice.
The Pharmacy Council register listed the pharmacist’s scope of practice as an intern.
The council’s website said an intern pharmacist practises under the supervision of a practising registered pharmacist “acts as a medicines manager, providing patient-centred medication therapy management, health improvement and disease prevention services in a collaborative environment”.
“Intern pharmacists ensure safe and quality use of medicines and optimise health outcomes by contributing to patient assessment and to the selection, prescribing, monitoring and evaluation of medicine therapy.”
In a statement to RNZ Pharmacy Council chief executive Michael Pead said whenever the Pharmacy Council received a notification of an incident, it began an “initial enquiry” to assess the situation.
“At the start of any enquiry, our focus is on ensuring there is no further risk to public safety. There are many ways to achieve this, including suspension of the pharmacist or pharmacists involved or a voluntary agreement that the individual/s will stop working.”
In order to ensure the inquiry into Bellamere’s death was “fair and thorough” and to avoid pre-empting any findings, the council could not provide any further details.
“We can confirm that the Pharmacy Council is comfortable that immediate steps have been taken to prevent the risk of further harm while the enquiry is ongoing.”
The owner of the Manawatū pharmacy that dispensed the medication earlier said in a statement to RNZ the baby’s death was “a tragedy”.
“Our sympathy is with the family and whānau. This is a very difficult time.
“We are looking into what has happened to try to understand how this took place. There will also be external reviews which we will work with.”
RNZ asked the owner how the medication was given at the wrong dosage, whether they disputed the allegations, when the pharmacy became aware the wrong dosage had been given, and what confidence people could have about other medication received from the pharmacy.
The owner said the pharmacy was “devastated about what has happened and are investigating to find out how this occurred”.
“It is not appropriate to comment further at this stage.”
On Thursday, a Pharmacy Council spokesperson said the council was looking into “what went wrong, how it went wrong, and who was involved”.
“However, in order to ensure our enquiry is fair and thorough, and to avoid pre-empting any findings, we cannot provide any further details at this stage.
“At the end of the process, we will make any recommended changes to ensure as best as possible an event like this does not happen again.”
The medication
While in hospital Bellamere’s mum, Tempest Puklowski gave Bellamere her drops for Vitamin D. Nurses also administered her phosphate.
When they left hospital they were given some Vitamin D in a little bottle, and a prescription for iron and Vitamin D.
The following day Bellamere’s father, Tristan Duncan went to a Manawatū pharmacy with the prescriptions. He was given the iron, but said the pharmacy refused to give the Vitamin D as the staff thought the dosage was “too high for her age and her weight”.
The staff said they would call the neonatal unit and follow-up.
A few days later Puklowski received a call from the unit to organise a home care visit. During the call she was asked if she had any concerns, and Puklowski asked if they had been contacted about the Vitamin D. They had not, and said they would follow up and rewrite the prescription along with a prescription for phosphate.
A day after the phone call, on July 2, Duncan went to the pharmacy to collect the medication and came home with just the phosphate. Unbeknown to the parents they had allegedly been given an adult dosage of phosphate.
The label on the medication directed them to dissolve one 500mg tablet of phosphate twice daily in a glass of water.
That evening they gave Bellamere her first dose of the medicine in her formula water. They would give her three bottles in 24 hours as was recommended.
The couple noticed in that period that her eating was off, and thought she was “extra gassy”, Puklowski said.
“She was still feeding fine. She just wasn’t maybe going through a whole bottle compared to what she was,” she recalled.
Then, the day after she got her first dosage Bellamere suddenly stopped breathing.
Bellamere was taken to hospital and rushed to the emergency department. Once she was stabilised she was taken to the neonatal unit where she stayed overnight before she was flown to Starship Hospital.
The couple had taken a bottle of the medicine with them to Starship Hospital. She gave it to the staff who saw that they had been given an adult dose.
The staff then requested the original prescription which confirmed the script had been written with the correct dosage, but somehow the pharmacy had given the wrong dosage, Puklowski said.
“I keep thinking about how much she ended up having and it just makes me feel sick.”
Tragically, Bellamere died at Starship Hospital on July 19.
On Wednesday, a Ministry of Health spokesperson told RNZ there were a number of investigations underway.
“Medsafe has completed an urgent assessment and is comfortable there is no immediate patient safety issue at the pharmacy. Medsafe will continue to work with Health New Zealand and these findings which will inform the information provided to the coroner. Medsafe is also sharing information with the Pharmacy Council.
“Once these reviews are completed, we will be able to look at next steps.”
Health Minister Simeon Brown told RNZ on Monday he raised the incident with the Director-General of Health as soon as he was made aware.
“She assured me that there would be an investigation undertaken by both the Ministry of Health and Health New Zealand. That investigation is underway.
“I am advised that this incident has led to Medsafe undertaking an urgent assessment of the pharmacy. A further investigation is being undertaken by the Pharmacy Council, and the death is also the subject of a coroner’s inquest.”
Health agencies would provide information to the coroner as needed to support the inquest.
“It is important that the reviews are undertaken, and that the circumstances that led to this incident are understood. I expect that these investigations may propose recommendations, and that these will be reviewed once reports are complete.”
rnz.co.nz
