Bellamere Duncan died in Starship Hospital on 19 July. Photo: Supplied
A pharmacy owner with more than 30 years experience in the field says the profession is under "immense pressure" and warns more "terrible incidents" will occur until the government sorts the workforce out.
"It's a terrible, terrible storm of events ... it's a recipe for disaster."
It comes after RNZ revealed Bellamere Arwyn Duncan died at Starship Hospital on 19 July. The two-month-old was allegedly given an adult dosage of phosphate by a Manawatū pharmacy. A coroner's preliminary opinion is she died from phosphate toxicity.
The revelations have 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 is also investigating, said it's "clear that an awful error has occurred".
Bellamere's parents are calling for a law change that would make it mandatory for medication to be checked by two people before it is dispensed.
Do you know more? Email sam.sherwood@rnz.co.nz
Pharmacist Annabel Turley, owner of Unichem Cashel Pharmacy in Christchurch, told RNZ the pharmacy workforce was under "immense pressure", adding both the current government and the last had "been dishing out pharmacy licences like lollies".
"We've got a severe workforce shortfall, and unfortunately, [they] have made it worse by allowing more and more pharmacies to open and the workforce isn't sorted. So they're essentially dishing out more licenses and diluting an already very fragile workforce," she said.
"I've been in pharmacy since the 90s, and I've never seen it so bad ... It's a terrible, terrible storm of events … it's a recipe for disaster."
She said it was "best practice" to have a second person check medication before it's dispensed, but in reality there were not enough pharmacists around in the country.
Turley said with the workforce under so much pressure mistakes were going to happen.
"We're not funded adequately by the government, and we haven't been for years," she said.
"We need to call out this government and the last government to put a halt to these pharmacy licenses because more and more terrible, terrible incidents that potentially are fatal are going to happen until they sort this workforce out. They need to stop issuing new pharmacy licenses so the workforce can start to recover."
Bellamere Duncan's parents were allegedly given an adult dosage of phosphate by the pharmacy. Photo: Supplied
Former pharmacy owner Ant Simon, who stopped practicing as a pharmacist in August last year after 40 years, told RNZ the pressure on the industry was one of the main reasons why he got out.
"I couldn't see the shortages ever getting any better. And we really struggled to get staff, and I just couldn't ever see it getting any better … if we were one person down, we were under severe pressure," he said.
"If you're under pressure you don't think as clearly. You're under pressure to get the work out, you're under pressure from the public and, yeah, that's when mistakes happened."
Simon said he would never want to practice without other pharmacists.
"We would have always have three, maybe four pharmacists on the team, and you've always got somebody else to check stuff with you. You could go along and say, 'Hey, do you think this right?' or 'What do you think about this? Can you please check my work?'".
He said the industry needed "more everything", including ensuring the country was able to retain new graduates.
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."
Support for law change
University of Otago's Dr Jason Wister, a Senior Medical Officer neonatologist and Dunedin Hospital's Neonatal Intensive Care Unit (NICU) clinical director, earlier told RNZ he was in favour of the suggested law change.
"I would be very supportive of that. That is the policy that we have in the NICU. I think that's fairly standard practice within NICUs, that all medications require two people to check them before dispensing.
"It seems like that would be a safe, low-risk, high-reward situation that would take very little time and effort to mandate."
Lanny Wong a pharmacist, director of Mangawhai Pharmacy and a member of the national executive of the Pharmaceutical Society told Checkpoint she was "fortunate" she had multiple pharmacists in her pharmacy, and had her prescriptions checked by another pharmacist if she was doing a "complex dispensing".
Asked if there needed to be changes mandating a second check, she said there did, but said pharmacists needed better support.
"I think it needs to change, but to change it, we need to be well resourced. We need to be well funded, and we need to be supported. That's what we need. But at the moment, we're simply not supported - let's just be frank, New Zealand pharmacy workforce is in crisis."
Bellamere Duncan's parents are calling for a law change that would make it mandatory for medication to be checked by two people before it is dispensed. Photo: 123RF
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."
The Pharmacy Council said it was unable to comment further when asked by RNZ on Monday whether it supported calls for a law change.
"Our enquiry and investigation processes are currently underway and, until these are complete, we cannot provide any further details. 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 owner of the Manawatū pharmacy that dispensed the medication 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."
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