A young woman given heart medication instead of the anti-depressant pills she needed suffered worse depression as a result.
Deputy Health and Disability Commissioner Rose Wall has released a report that found a pharmacist with decades of experience last year dispensed the wrong medication to the 26-year-old.
She was given the heart medication Duride, which is used to treat angina, rather than the anti-depressant fluoxetine.
Over almost three months, her mood worsened, she struggled to find work and lost a key relationship.
It was a serious breach of health regulations, Ms Wall said.
"It just highlights the importance of the correct medication being dispensed. The pharmacist could provide no explanation for his error."