While working on a busy ward, a nurse accidentally administered the wrong medications to a patient without the appropriate checks. The nurse soon realised her medication error but did not report it. The patient passed away a few hours later. The nurse did not disclose her error until two days after the patient's death and, following an investigation and breach finding by the Health and Disability Commissioner, the Director of Proceedings laid charges against the nurse in the Health Practitioners Disciplinary Tribunal.

The nurse accepted that the charges of professional misconduct had been fully made out. The Tribunal agreed, and emphasised that while the medication error did itself constitute misconduct, the medication error alone would not have been sufficient to warrant disciplinary sanction: "the circumstances were such that [the Tribunal] can understand how the mistake occurred". However, the nurse's failure to make appropriate checks before administering the medications, and her failure to report her error clearly warranted disciplinary sanction. The Tribunal noted that: "It is essential in the practice of nursing, as any other health profession, that there be full, free and frank disclosure of any error" and that: "a clear message needs to be sent to the nursing profession and to the public that nurses should avoid errors, but if there is error of any kind, then the obligation is on the nurse to ensure that all steps are taken as quickly as reasonably possible...". While the Tribunal was of the view that a 12 month suspension would have been appropriate, it concluded that suspension was unnecessary having regard to the nurse's long term of unemployment and her decision not to seek re-employment as a nurse. The nurse was censured and conditions were placed on any return to practice. The nurse was not fined but was ordered to pay one third of costs. 534/Nur12/227D