Report reveals what went wrong before baby Bellamere Arwyn Duncan's fatal overdose

Bellamere Arwyn Duncan

Photo: Supplied

A two-month-old baby died from an overdose after she received phosphate at a dose 13 times higher than prescribed, a report has revealed.

A review into the death of Bellamere Arwyn Duncan, who died after she was dispensed an adult dosage of medication, has found the systems and processes in place at the time "did not provide the safeguards necessary" to prevent it.

A Health New Zealand review said there were multiple factors at play in her death including discharge planning, communication with the family and community pharmacy process.

"While the prescribed dose, if dispensed correctly, would have been safe, the review has identified that the systems and processes in place at the time did not provide the safeguards necessary to prevent this tragic event."

RNZ earlier revealed Duncan died at Starship Hospital on 19 July 2025. A Manawatū pharmacy dispensed an adult dosage of phosphate to the two-month-old's parents. A provisional post mortem report said 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. The Pharmacy Council was also investigating.

Medsafe review

On Friday, Medsafe released a summary of its findings into Duncan's death.

The summary said Duncan received phosphate at a dose about 13 times higher than that prescribed by the medical practitioner.

The hospital prescription, which included Duncan's date of birth and age in weeks, was forwarded to a community pharmacy for dispensing.

"When processing the prescription, an intern pharmacist generated a dispensing label with incorrect dosage instructions."

The dispensing label said to "take one tablet twice daily. Dissolve in a large glass of water".

The processed prescription was dispensed by a trainee technician.

"The pharmacy was able to demonstrate that a 'final check' of the prescription was conducted by a pharmacist; however, the accuracy and clinical appropriateness checks by the pharmacist were insufficient to identify and respond to the error."

The summary also said counselling was not provided to Duncan's father when the prescription was collected.

Medsafe said the "primary root cause" of the dispensing error was the "checking activities conducted by the pharmacist, including checking for clinical appropriateness and dispensing accuracy".

"This was particularly significant given the age of the patient."

There were a number of "contributory factors" relating to the pharmacy practice activities.

This included failing to identify that the prescribed dose required dilution, and a "busy pharmacy environment".

"Medsafe considers there were several potential opportunities during the dispensing process for interventions to have been made that may have identified the dispensing error."

Chief Medical Officer Dr Joe Bourne said Duncan's death had a "profound impact" on her family and the health professionals and organisations responsible for caring for them.

"The incident prompted a coordinated, whole-of-system response, focused on understanding what happened and identifying opportunities to strengthen patient safety."

Dr Bourne said Medsafe would be continuing to work with Health New Zealand, the Pharmacy Council and the pharmacy sector to support improvements that reduce the risk of similar events in the future.

Bellamere Duncan's parents were given an adult dosage of phosphate by the pharmacy.

Photo: Supplied

'Multiple factors' at play - Health NZ

On Friday, Health NZ said in a statement they had completed a serious adverse event review following Duncan's death.

MidCentral Chief Medical Officer Dr Claire Hardie said while her death remains before the Coroner, Duncan died following an unintentional overdose of oral phosphate.

"The purpose of the Serious Adverse Event Review was to identify opportunities for learning and improvement so we can reduce the chances of such a tragedy happening again.

"The review process has included whānau, clinicians, Medsafe and representation for the community pharmacy provider which dispensed the prescription for oral phosphate."

Hardie said the review highlighted there were "multiple factors" at play.

"Those factors included discharge planning, communication with the family and community pharmacy process.

Hardie said the review identified "recommended actions for improvement" such as updated guidance for managing Metabolic Bone Disease in premature infants at MidCentral and strengthening clinical documentation

It also recommended training on safe prescribing and administration of paediatric medications, review of discharge procedures within the Palmerston North Hospital neonatal unit and develop a process for changes to any discharge plan to be clearly documented.

It also supported the introduction of electronic prescribing for outpatients nationally.

"We are committed to implementing the recommendations from the review which fall within our responsibilities and have an action plan and monitoring programme in place to support this work.

"We would like to extend our condolences to the whānau for their loss and thank them for sharing their experience as part of the review process. The learnings from this review are helping us to put processes and improvements in place that should prevent such a tragedy from happening again."

Three staff involved in error

The owner of the Manawatū Pharmacy earlier emailed Bellamere's parents with a summary of what happened.

The owner said the pharmacy's standard dispensing process involved intern pharmacists entering each prescription into the dispensary computer. The pharmacy used a dispensing system called Toniq.

A technician would then use the information in Toniq and the prescription to identify the medication and put the correct amounts in containers. The labels were then printed out and placed in a basket with the original prescription and the medication. A registered pharmacist would then check the prescription, the labels and the medication itself before it was given to the patient.

The owner said the pharmacy received the prescription by email on 1 July from Palmerston North Hospital.

The prescription was entered into Toniq by an intern pharmacist.

"This person unfortunately misread the prescribed dosage and entered the prescription dose as '1 tablet twice daily' rather than '1.2 mmol twice daily'," the owner said.

The Toniq system then generated an original label for the prescription.

"This includes a warning label with the patient's age, if they are under 18 years old, and if the patient has not been prescribed the medication before.

"The second warning prompts the checking pharmacist to counsel (speak with) the patient or their caregiver about how to take the medication."

The product was supplied in tubes of 20 tablets. The trainee technician printed out three further labels. They were to be placed on the three tubes that were being dispensed.

"This was the trainee technician's first time handling a phosphate product. She was also unfamiliar with the mmol dosage. She did not notice the dosage error as a result. She put the original prescription, labels and the medication in a basket on the dispensing bench for the registered pharmacist to check.

"Unfortunately, the original label and the warning label was not kept with other items."

The registered pharmacist who carried out the final check did not pick up that the medication was for an infant, the owner said.

"In addition, it was not identified that this was a new medication. The fact that the warning label was not retained contributed to this error."

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