During a patient's hospital admission, a registered nurse noticed that the medications listed on a patient's medication sheet did not match the medications logged in the Pyxis medicines administration system. The nurse overrode the system and administered the medications. A short time later the nurse realised she had clipped the wrong medication sheet into the patient's file and had therefore administered medications intended for another. The nurse did not report the error but did check a pharmacy reference text and decided that the patient was not in danger. The patient's condition deteriorated and he died two hours later.

The nurse reported her error two days later. The patient's body had to be uplifted for a post-mortem and the pathologist concluded that the medication was contraindicated. The Commissioner found the nurse in breach of the Code for failing to take steps to ensure the correct medication was administered, failing to appreciate the significance of the patient's deterioration, and for the "severe" failure to report the error and mitigate the danger to the patient. While the DHB's various policies, procedures and training systems were reviewed as part of the investigation, the Commissioner found that "the breaches in this case were caused by individual error". The nurse was referred to the Director of Proceedings. 10HDC01201