An elderly woman has died after she was given the wrong medication by a caregiver at her rest home.
A caregiver was completing rounds at the residential facility when she gave a 96-year-old woman medication that were intended for another resident in early 2013.
The medication was used to treat high blood pressure.
When she returned to her cart she recognised her error and called the on-called resident nurse an hour later to let her know and ask for advice.
The registered nurse told her to check on the elderly woman every 20 minutes, but within the hour she was semi-conscious, prompting the caregiver to call the nurse a second time.
The nurse told her to contact another professional who was off-duty at the time to come help, and together they managed to get the elderly woman to the local emergency department via ambulance.
However, the elderly woman died from the blood pressure medication.
Deputy Health & Disability Commissioner Rose Wall found the caregiver breached the woman's rights when she failed to notify a nurse of her error straight away.
Ms Wall also found the registered nurse who was initially contacted did not act with sufficient urgency and her dual-employment at another care facility was an unprofessional arrangement.
Both have been asked to apologise to the elderly woman's family while the Nursing Council of New Zealand have also been asked to consider reviewing the nurse's competence.