The Waikato District Health Board has been criticised over the way it administered paracetamol to a frail, elderly woman who subsequently died.
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The Health and Disability Commissioner said the dose given was too high, and DHB staff failed to adjust it to meet her needs.
The 77-year-old woman was frail and underweight when she had bowel surgery.
She recovered initially, but then deteriorated and died.
An autopsy revealed no sign of toxicity from paracetamol, but the Commissioner Anthony Hill says giving her three or four grams a day was too much for her circumstances.