An elderly woman who died from kidney failure after being given clashing medications was let down by her doctor, pharmacy, DHB and rest home, the health watchdog says.
A report from Health and Disability Commissioner Anthony Hill has found the 78-year-old woman was given a treatment for a rash, ketoconazole, that was not meant to be taken with simvastatin - her cholesterol medication.
After a fall in 2012, the woman was taken to hospital, where it was only six days later discovered she had been given the pills over 18 months - after ketoconazole was left off her medical charts.
Shortly after the woman suffered kidney failure and died.
Mr Hill found the pharmacy that dispensed the medication three times over 18 months had software that highlighted clashes, but never contacted the woman's GP.
Meanwhile, the doctor had failed to properly looking into the woman's medical history, Mr Hill said.
"When prescribing medication to a patient, doctors must ensure they are familiar with the patient's medical history in order to assess the patient's needs adequately and to satisfy themselves that the medication will be in the patient's best interests."
Auckland DHB had also not ensured staff had proper access to her recent medical records and the rest home was criticised for not completing progress notes on a regular basis, and for a lack of nursing support.
Mr Hill recommended the Medical Council of New Zealand look into a review of the doctor's competence.
He also suggested the pharmacy chain obtain an independent review of its dispensing procedures for all its branches.