Bellamere Duncan died at Starship Hospital on 19 July. Photo: Supplied
Pharmacy owners have written to the government calling for "urgent" action, warning "lives are at stake" following the death of a two-month-old baby after she was allegedly given medication at an adult dosage by a pharmacy.
"We owe it to this child - and to every New Zealander - to fix a system that is failing," one pharmacy owner said.
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.
Pharmacist Annabel Turley, owner of in Christchurch, earlier 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".
Turley wrote to several ministers including former Health Minister Dr Shane Reti and Prime Minister Christopher Luxon in October last year.
"I write to bring to your urgent attention the critical workforce shortages that are endangering the sustainability of pharmacy services across the country," she said.
Turley warned the profession was "at a tipping point".
"Pharmacists have been front-line healthcare providers for years, offering critical services such as medication management, vaccinations, and health advice, particularly during the COVID-19 pandemic.
However, many pharmacies are under immense pressure without sufficient staffing, and our ability to maintain these essential services is seriously jeopardised."
She called for an "immediate moratorium" on issuing new licences for greenfield pharmacy sites until the workforce situation was addressed.
"Opening new pharmacy sites in the current climate only exacerbates the strain on an already overstretched workforce. Without adequate staff, these new pharmacies will struggle to function, and existing pharmacies will be further depleted of resources, spreading our already thin workforce even more thinly."
On Thursday, Turley sent another letter to the Prime Minister, Health Minister Simeon Brown and other politicians.
In the letter, seen by RNZ, Turley said since her letter the profession had seen "no significant improvement in workforce stability".
She said Bellamere Duncan's death was "not an isolated incident".
"It is a symptom of a workforce under immense pressure-burned out, short-staffed, and stretched to breaking point.
"Pharmacists are no longer able to guarantee safe, consistent care in all circumstances. As one of the few remaining accessible front-line health services in many communities, this is not just a pharmacy problem-it is a public safety issue."
Turley said, unless "bold steps are taken", including an immediate halt on new greenfield pharmacy licences, there would be "more preventable tragedies like this one".
"We owe it to this child - and to every New Zealander - to fix a system that is failing," she said.
"Lives are at stake. Let's not allow another preventable tragedy to occur."
Turley welcomed the opportunity to meet with the ministers to discuss solutions "to this crisis".
"We all want a pharmacy sector that is safe, sustainable, and resilient-and we need your leadership now more than ever to make that happen."
Bellamere Duncan's parents were allegedly given an adult dosage of phosphate by the pharmacy. Photo: Supplied
Another pharmacy owner and pharmacist, Anna Hewitt, wrote to Brown, Luxon and other ministers on Wednesday.
"Last week, our worst fear took place. A baby lost its life as a direct result of this Crisis. The critical workforce shortage has endangered the sustainability of Pharmacy in NZ and now it is having direct consequences on our Patients."
Hewitt said the workforce was "stretched, it is overworked, and close to burnout".
"This is not just a workforce issue, it is a Public Health Crisis. Pharmacists and Pharmacies are highly specialized, and the first point of call for many patients who cannot access timely health services.
"We dispense and catch prescribing errors, we advise both other health professionals and the public on medication use, we vaccinate, we treat, we prescribe in many cases. But we are not superhuman, we cannot continue like this with no support."
Hewitt referenced Turley's letter from last year.
"I know firsthand that other Pharmacists from around the country have also written letters to call for action within the sector. These calls have fallen on deaf ears as it seems."
She said the Government had added Pharmacists to the immigration green list and opened a new pharmacy school at the University of Waikato, which while they were steps in the right direction, they were "medium- and long-term solutions to a problem which is in immediate crisis".
"This isn't just numbers, this isn't just words on a page, this is real lives, real patients, real pharmacists who are desperately trying to hold it together, and care for their patients. The human face of this crisis is Bellamere Arwyn Duncan."
Hewitt called for the Government to stop issuing new pharmacy site licences and to look closely at how pharmacies were funded.
"We owe it to this beloved child that was lost, we owe it to all New Zealanders, we need to fix a system that is failing."
Pharmacists have written to health minister Simeon Brown to voice their concerns. Photo: RNZ / REECE BAKER
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."
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."
A Health New Zealand (HNZ) spokesperson told RNZ pharmacies "play an important role in providing much needed access to healthcare services for our communities".
"Health New Zealand recognises how committed pharmacists are to their patients and that they are a critical part of our healthcare system," they said.
HNZ contracts with more than 1000 community pharmacies throughout New Zealand to provide pharmacy services to all New Zealanders.
"Through this contract, there are audit requirements related to service delivery standards. The goal of the audits is to ensure high quality care."
As part of HNZ's workforce plan, there is funding allocated to continue to grow ancillary pharmacy workforces, particularly Pharmacy Accuracy Checking Technicians and support the development of pharmacists in gaining additional qualifications to become prescribing pharmacists.
"Health New Zealand is also working with community pharmacy on ways to make better use of our pharmacists' clinical skills to provide additional services to consumers. We have already extended funding for immunisations to pharmacies, and they are now providing the majority of influenza's vaccinations."
HNZ also has an interim policy framework that it applies in considering applications for new pharmacies to be opened, and has work planned to develop a future focused framework for application reviews.
A Medsafe spokesperson said the number of pharmacies had remained "consistent" over the past five years, reducing slightly from 1105 in March 2020 to 1089 in July 2025.
Under the Medicines Act, Medsafe must issue a licence to any pharmacy which meets the legal criteria. The Act has no restrictions on the number of pharmacies allowed to operate.
"The Ministry recognises how tragic this event was, and our heartfelt condolences are with the family. We want to emphasise that serious errors like this are extremely rare. The vast majority of people who access pharmacy services receive safe and quality care."
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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