Trigger warning: This piece contains details surrounding the loss of a baby
A two-month-old baby has died after allegedly being given an adult dose of medication by a pharmacy, prompting a wave of grief, regulatory scrutiny, and calls for urgent reform, RNZ has reported.
The infant, Bellamere Arwyn Duncan, died on 19 July after her parents say she was mistakenly dispensed phosphate at an adult dosage. The baby’s parents, Tempest Puklowski and Tristan Duncan, are now calling for a change that would mandate a two-person verification system for dispensing medication.
The Ministry of Health and Health New Zealand have launched a joint review into the incident. Medsafe, the regulatory body for medicines, has already visited the pharmacy involved and determined it may continue to operate. The Pharmacy Council, also investigating, acknowledged that “an awful error has occurred," RNZ reported.
Early Life and Hospital Discharge
Born prematurely at 31 weeks and five days on 2 May at Palmerston North Hospital, Bellamere weighed just over one kilogram. Her parents were prepared for an early birth but not as early as it came.
Bellamere remained in the neonatal unit for nearly two months. On 24 June, she was discharged, and her mother was overjoyed to finally bring her baby home.
While in hospital, Puklowski administered Vitamin D drops and nurses gave Bellamere phosphate. Upon discharge, the family was given a bottle of Vitamin D and a prescription for iron and Vitamin D.
The Pharmacy Visit and Dosage Concerns
The following day, Duncan visited a Manawatu pharmacy with the prescriptions. The iron was provided, but staff refused to fill the Vitamin D order, citing concerns the dosage was too high for Bellamere’s age and weight. They said they would contact the neonatal unit.
A few days later, during a call from the neonatal unit to arrange a home visit, Puklowski asked if there had been any communication from the pharmacy. There had not. The unit said they would follow up and rewrite the Vitamin D prescription, adding phosphate as well.
By 2 July, Duncan returned to the pharmacy and was given only the phosphate. Unbeknownst to them, it was allegedly an adult dosage. The label instructed them to dissolve one 500mg tablet in water twice daily. The parents, trusting the professionals and reassured by the earlier caution over the Vitamin D, did not question the phosphate instructions.
That evening, Bellamere received her first dose. Over the next 24 hours, she had three bottles with the medication mixed into her formula. Her parents noticed she was gassy and eating less but still feeding.
Then, suddenly, she stopped breathing.
Emergency Response and Tragic Outcome
Puklowski described the panic that followed. “Tristan had to start administering CPR, and I was on the phone to the ambulance,” she said. Paramedics arrived within minutes, RNZ reported.
Bellamere was rushed to hospital, stabilised, and then transferred to the neonatal unit. She was later flown to Starship Hospital in Auckland. The parents, confused and terrified, informed doctors about the recent medication change. Staff at Starship identified the phosphate as adult-dosed and requested the original prescription, which confirmed the correct dosage had been prescribed.
Initially given hope by signs of movement and alertness, the couple were later told to prepare for difficult decisions. Bellamere died on 19 July. A preliminary coroner’s opinion attributes her death to phosphate toxicity.
Family and Regulatory Responses
The parents are devastated.
The owner of the Manawatu pharmacy described the death as a “tragedy” and said the pharmacy is cooperating with all external reviews. They declined to comment further while investigations are ongoing.
Duncan called the incident “negligence,” while Puklowski questioned how such an error could pass unnoticed—particularly after the Vitamin D concern. “It just makes no absolute sense,” she said. The couple are advocating for system-wide changes to medication dispensing processes, especially involving children.
Pharmacy Council and Government Action
Pharmacy Council Chief Executive Michael Pead expressed condolences and acknowledged a serious error had occurred. The Council is working to determine exactly what went wrong and who was involved. Pead said the incident has been referred to other relevant organisations and emphasised that such cases are extremely rare.
Dispensing procedures typically involve multiple checks, including a final verification by the pharmacist. While double-checking is best practice, in some cases—such as a sole-charge pharmacist—it may not be feasible.
Health New Zealand and the Ministry of Health also offered their condolences and are urgently conducting a joint review. Medsafe’s visit to the pharmacy included a rapid audit, which concluded the facility could remain open.
Health Minister Simeon Brown called the death “heartbreaking” and said all appropriate regulators have been advised and are taking necessary steps
ISSUE
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