A mix-up in medication dispensed by a pharmacy may have
contributed to the death of an elderly Ranfurly man but it was
hard to determine to what extent, the Alexandra Coroners Court
The Otago-Southland coroner, David Crerar, reserved his
finding after an inquest into the death of Nine Pahau Paku
(Eru) Te Weehi (73). Mr Te Weehi died in Dunedin Hospital on
January 5, 2011, five days after being given another man's
medication by mistake, in weekly ''blister packs'' dispensed
by Larson's Maniototo Pharmacy.
Detective Alan Lee, of Alexandra, said after considering two
pathologists' reports following Mr Te Weehi's death, police
had decided against laying criminal charges, saying a
successful criminal prosecution was unlikely. The pharmacist
in charge at the time, Joseph Stevenson, gave evidence and
then apologised to Mr Te Weehi's family, who were in court
''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, it was. It was my fault,'' Mr Stevenson said.
The blister packs were pre-filled and checked by him, stacked
in the pharmacy dispensary, on top of a sheet of paper with
the patient's name on it. On top of each stack was a plastic
container, which held a blister pack and displayed the day
and time the medication should be taken. The container had
the patient's name on one or two ends.
When Mr Te Weehi's neighbour, William John Burrows, collected
the medication on behalf of Mr Te Weehi on December 31, Mr
Stevenson took the container from the top of the stack. It
had the correct name on one end. He did not check both ends,
but put the container into the plastic shopping bag he was
given. A pharmacist at Dunedin Hospital contacted him after
Mr Te Weehi was admitted to hospital and said the man had
been given the wrong medication and the medication list on
the plastic container had another man's name on it.
Dr Verne Smith, of Ranfurly, said Mr Te Weehi, his patient
for 21 years, suffered from heart disease, alcoholic
cardiomyopathy, atrial fibrillation, alcoholic liver disease
and heart failure.
The coronial autopsy report by Prof Han-Seung Yoon said
thecause of death was multi-organ failure in association with
an overdose of hypoglycaemic drugs, lactic acidosis, aged
myocardial infarcts, severe emphysema, alcoholic
cardiomyopathy and liver steatosis.
A second pathologist's report, from Dr Martin Sage, said it
was ''entirely reasonable'' to suggest the Metformin given by
mistake to Mr Te Weehi might have contributed to his death
through lactic acidosis, but concluded ''I cannot determine
with any degree of precision the extent of that contribution,
certainly not to the standard required for a criminal
Det Lee said Mr Te Weehi's cousin, Tania Nixon, did not want
the pharmacist held accountable, as her cousin had been
''seriously ill with multiple problems brought on by
long-term alcohol abuse''. The family had no ill-feeling
towards Mr Stevenson, she told police.
Mr Burrows visited Mr Te Weehi on January 5. His neighbour
was in bed, obviously ill, and an ambulance was called. Mr
Burrows noticed Mr Te Weehi had not taken his pills for the
previous two days.
Mr Stevenson said procedures had since changed, and extra
checks, matching medication and names, were included. The
other man in the mix-up had been contacted as soon as he
realised the mistake. Pharmacy Defence Association of New
Zealand executive officer Carolyn Hooper, of Wellington, a
pharmacist, said her role was to support pharmacists who made
an error, ''so I see many hundreds a year''.
Mrs Hooper was asked by the coroner whether the mistake in
this case was common. She said it was ''not unusual for a
patient to receive someone else's medication''. Sometimes
that was because patients got tired of waiting for a
prescription to be filled and answered to someone else's name
or, in other cases, they might be wrongly identified.
The different-style, improved ''blister packs'' now used by
the Ranfurly pharmacy would reduce the risk of error as they
contained the patient's name on every section, she said. The
improved packs superseded the old packs and were used by most
pharmacies around the country.