A pharmacist who dispensed out-of-date and incorrect insulin to a diabetic patient could have his competence reviewed.
A report by the deputy Health and Disability Commissioner, Rae Lamb, says the patient questioned the pharmacist twice about the insulin he was dispensed in November 2007.
He became sick because it was the wrong type, and later discovered it was 18 months out-of-date.
The report says the incident was significant and could have had serious consequences.
The deputy commissioner has recommended the Pharmacy Council consider the pharmacist's competence to practice, and the Ministry of Health consider an audit of procedures.