A pharmacist may face legal action after accidentally giving an elderly man the wrong drug and then lying to cover up his mistake.
A 79-year-old man was dispensed a chemotherapy drug to treat cancer instead of an immunosuppressant drug he needed following an organ transplant.
An investigation by Deputy Health and Disability Commissioner Theo Baker found the man was given cyclophosphamide tablets instead of cyclosporine capsules during a 2013 visit to an unnamed pharmacy.
When he returned for routine tests seven weeks later the man asked why his medication looked so different and was told by the dispensing pharmacist it was a discontinued form of his original medication. The patient was told to resume taking the original pills.
The pharmacist, named only as Mr C, did not tell the pharmacy owner of his error, did not complete an incident form, and when questioned about stock levels, did not disclose his mistake.
It was only admitted two days later when the patient returned to meet with the pharmacy owner privately.
In his submissions to the commissioner, the pharmacist apologised for the error which was "deeply regrettable and... truly out of character for me."
But he made excuses, saying he had a heavy workload and long hours, claims disputed by his boss.
He also said he hadn't reported it because it "went to the back of my mind" and he was keen to avoid conflict with the owner, explanations Ms Baker did not accept.
The deputy commissioner called the initial error a "serious lapse of judgment" that put the patient at significant risk of harm.
She also dismissed his explanation that he told the patient the drug was discontinued so as not to alarm him.
"Consumers have a right to know what has happened to them when an error has occurred," Ms Baker said.
The pharmacist was referred to the independent director of proceedings to decide whether legal action should be taken against him.