The Wairarapa District Health Board has apologised to the family of an 82-year-old man who was given the wrong drug following a stroke and died.
A number of mistakes were identified in an investigation into the death of the man, who was treated at an unnamed emergency department in late 2011 for a suspected stroke.
Health and Disability Commissioner Anthony Hill found the DHB breached the patient's rights, in a decision released on Tuesday.
A house surgeon, or recently qualified doctor, had followed the hospital's stroke protocol, which was to administer a thrombolysis drug referred to as a "t-PA".
However, the only drug available was tenecteplase, where the manufacturer's maximum dose limits where much less than what the hospital would normally administer.
The house surgeon rang another hospital where a doctor told him he could use tenecteplase.
However, the second doctor was not aware it was for a stroke patient.
The tenecteplase was administered and the next day the patient deteriorated with bleeding on his brain and died three days later.
"The man should have been given the t-PA drug alteplase," Mr Hill said.
"Tenecteplase should not be used for the treatment of stroke, and is used only for treatment of heart attacks."
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Confusion over stroke drug led to death