A seven-year-old boy ended up in an emergency department three times and now has to be fed through a tube after a pharmacy accidentally gave him 10 times the dosage needed of a medication.
Deputy Health and Disability Commissioner Meenal Duggal on Monday released a report criticising two pharmacists for failing to properly dispense medication to the child's mother.
The commission heard the boy with cerebral palsy was given a dosage of muscle relaxant baclofen 10 times times larger than needed in late November, 2014.
In 2015, he ended up in emergency departments three times because of increased seizures and shortness of breath and weight loss - with the error only being discovered on the third visit.
The boy's mother told the commission that at the third visit he commenced feeding through a tube and could still not be fed orally.
"[The mother] has informed this office that [the boy] enjoyed food, and that his quality of life decreased because of the nasogastric feeding," the report said.
Ms Duggal has recommended both pharmacists be assessed and apologise to the woman, while the pharmacy was advised to conduct and audit of staff compliance.