A pharmacy dispensing error resulted in the death of two-month-old Bellamere Arwyn Duncan after the infant was given a dose of phosphate roughly 13 times higher than prescribed.
Medsafe on Friday released a case summary detailing the in July 2025 incident, which occurred when an internet-processed hospital prescription was forwarded to a community pharmacy in Manawatū.
Duncan was prescribed Phosphate Phebra 1.936g effervescent tablets at a dose of 1.2 mmol twice daily. Each tablet contains 500mg of elemental phosphorus, which is equivalent to 16.1 mmol of phosphate.
To achieve the prescribed 1.2 mmol dose for a pediatric patient, guidance protocols indicate one tablet should be dissolved in 16ml of water. A caregiver must then draw up 1.2ml of the solution to administer to the child, while discarding the rest.
However, when processing the prescription, an intern pharmacist generated a dispensing label with incorrect dosage instructions. The label directed: “Take one tablet twice daily. Dissolve in a large glass of water.”
