A rest home and two nurses have been found in breach of the Health and Disability code after giving an elderly man five times more morphine than he should have had.
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The man in his 80s was a patient at Molly Ryan Lifecare in New Plymouth. He died hours after being given the pain medication.
He was prescribed morphine for the pain management of multiple existing health conditions.
"One morning, a registered nurse and two caregivers were on duty.
"None of these staff members had met the medication competency requirements set out in the rest home's medication management policy," the report said.
Without that requirement, staff were unable to administer medicines, such as morphine.
Deputy Health and Disability Commissioner Rose Wall said during the shift the nurse was told the man was in distress.
"She drew up 2.5ml of subcutaneous morphine solution without checking the prescribed route of administration or calculating the dose.
"The solution administered to the man contained 25mg of morphine, which exceeded the maximum quantity prescribed by a factor of five."
The report said he was given the medication early in the morning, was unresponsive in the afternoon, and by the evening had died.
Wall said the rest home had failed to provide adequate care from properly trained, qualified and experienced staff.
It also failed to ensure that the systems in place were sufficiently robust and made sure staff complied with its medication management policy, she said.
"Medication-competency training had not been fully completed by staff with responsibility for medication management before they were rostered on duty and, as such, the staff concerned were not supported to administer medication safely, and were not suitably skilled to deliver the standard of care required."
The deputy commissioner was also critical the rest home told the man's family and Enduring Power of Attorney about the medication error before consulting with the executor of his will.
Wall said the nurse who supplied the man with medicine breached the code for not checking how to give him the drug or calculating the appropriate dose.
Another nurse was censured for not making sure staff trained in administering drugs were on shift.
Both nurses and the rest home must have been asked to provide written apologies to the family.
Wall asked that the rest home audit every shift for a month to ensure the right number of trained staff were on duty.
