A coroner has found a Dunedin man died from a medication overdose due to mistakes made by his doctor and pharmacist.
Kenneth Douglas, who was 72, died in 2012 from an internal haemorrhage caused by a drug he was taking for arthritis, methotrexate.
The drug is normally prescribed weekly because it can have serious side effects but Mr Douglas' doctor, Anne-Marie Tangney, accidentally prescribed a daily dose.
Chris Devonport said that initial mistake was not picked up by the pharmacist, even though expert witnesses said it should have been basic knowledge.
The coroner said if staff at the pharmacy had provided the checks they should have, Mr Douglas's death could have been avoided.
One pharmacist was reviewed by the Pharmacy Council, which appointed a mentor to supervise the pharmacist for a year.
The doctor involved is still practising.