Man got wrong medicine, inquest told

18:54, Mar 19 2013

A medication pack which included medicine for a diabetic patient was dispensed to the wrong man by a pharmacist in Ranfurly and has been linked to his death.

At an inquest, held in Alexandra yesterday, Otago Southland coroner David Crerar was told Nine Pahau Paku Te Weehi, known as Eru, died on January 5, 2011, after being flown to Dunedin Hospital on January 4.

Mr Te Weehi, who suffered from heart disease, alcoholic cardiomyopathy, atrial fibrillation, alcoholic liver disease and heart failure, was found "in a bad way" in his bed by a friend the day before his death at his Ranfurly home.

An ambulance was called and staff decided to call a rescue helicopter. It was when an ambulance officer turned Mr Te Weehi's medication tray upside-down to get the correct spelling of his name that it was discovered he had been given the wrong tray or "blister pack".

Former Larson's Maniototo Pharmacy pharmacist Joseph Stevenson was spoken to by police on January 6, 2011, and said he had "made a mistake" and accidentally handed over medication for another patient to a friend of Mr Te Weehi on December 31.

Mr Stevenson said the friend would often pick up Mr Te Weehi's medication when he was too ill and on that day he had been distracted and had put the blister pack straight into a bag the friend provided.


He did not check to make sure the right medication on Mr Te Weehi's prescription list was the prescription in the blister pack and tray being provided for him.

He said he would usually check the medication when walking back from the storeroom to the counter but on this day he had put it directly into the bag.

"My job is to check medication against the list and the tray. I always check it and it has never been wrong. The one time I haven't [checked] it was. It was my fault," Mr Stevenson said.

It was noted an earlier mistake had been made on a separate occasion when two patients with similar names were given the wrong medication packs. One of the patients noticed the error and the medication was brought straight back.

Since Mr Te Weehi's death the pharmacy changed from Nomad brand medication packs to Medico packs, which had a patient's name printed clearly on the pack.

Pharmacy Defence Association executive officer Carolyn Hooper said it was not uncommon for patients to get the wrong medication and hundreds of cases were dealt with every year.

Mr Crerar formally found Mr Te Weehi's death was caused by multi-organ failure and lactic acidosis in association with an overdose of hypoglycemic drugs, aged myocardial infarction, severe emphysema, alcoholic cardiomyopathy and liver steatosis.

Detective Alan Lee, of Alexandra, said two pathologists had found that while an incorrect administration of Metformin, a diabetic medication, may have contributed to Mr Te Weehi's death it was not to the standard required for criminal prosecution.

The coroner reserved his formal recommendations in writing.

The Southland Times