Nelson-Marlborough District Health Board (DHB) has been censured after a 64-year-old mental health patient died after receiving an overdose of medication.
The patient, identified only as Mr A, died after being given an overdose of fluphenazine decanoate at the DHB's mental health acute care unit.
Mr A suffered from extreme psychosis and was considered a risk to himself and others. He was given fluphenazine injections in 2008 after refusing to take oral medication.
After an initial improvement, Mr A's physical and mental health deteriorated and he died in early 2010.
A report released today by the Health and Disability Commissioner (HDC) found the DHB gave Mr A more than the recommended quantity of medication for a man of his age with dementia.
He was given between 162.5-225mg over about 40 days when the recommended dose was 22-75mg every three weeks.
It also found the DHB breached the Health and Disability Consumer Rights Code for failing to provide the drug with reasonable care and skill, failing to clearly record its use and failing to have a plan for managing Mr A's behaviour and hygiene.
The HDC recommended the DHB prepare a policy for the care of geriatric patients with psychiatric problems.
