INVESTIGATION: NZ doctor performed euthanasia without legally required review, using another patient’s expired drugs
EXCLUSIVE: A New Zealand doctor carried out euthanasia using expired lethal drugs prescribed for another patient, before the legally required compliance review had been completed, official documents obtained by Voice For Life reveal.
Voice For Life launched an investigation after closely examining a complaint recorded in the Registrar's 2024 annual report while it was conducting a five-year review of euthanasia and assisted suicide in New Zealand.
The investigation involved multiple Official Information Act requests to government agencies, including Health New Zealand, the Ministry of Health, New Zealand Police and the Health and Disability Commissioner, as well as correspondence with the Medical Council of New Zealand.
Documents obtained revealed the seriousness of the incident, how it came to light and how Health NZ responded as events unfolded. They also expose serious flaws in the euthanasia system, raising serious questions about the management of lethal drugs, the effectiveness of safeguards, and the adequacy of monitoring and oversight.
The incident, which occurred in March 2024, came to Health New Zealand’s attention only after a clinical advisor contacted the doctor involved to request completion of a new form, believing the assisted dying compliance process was still underway.
The doctor replied that the patient was already dead. No safeguard mechanism had been triggered.
Within hours, checks revealed that no prescription had been issued from the dispensing pharmacy for the deceased patient, and drugs previously supplied for another patient had never been returned to the pharmacy.
Health New Zealand subsequently confirmed that the euthanasia had occurred without the Registrar's compliance review, a requirement under the End of Life Choice Act 2019.
Its internal investigation also established that the drugs used had been prescribed more than eight weeks earlier, had passed their expiry date, and were labelled with another patient's identifying information. Again, no safeguard prevented the action.
The incident was referred to New Zealand Police, the Health and Disability Commissioner (HDC), and the Medical Council of New Zealand.
Despite an in-depth Police investigation, no charges were laid.
In a response Voice For Life enquiries, dated 5 October 2026, Police stated: “Police determined that it was not in the public interest to lay charges in relation to this matter and subsequently filed the investigation.” The investigation concluded on 9 June 2025.
Police have not disclosed their reasons for reaching that public-interest decision, nor whether investigators concluded that a particular criminal offence had been committed.
They have also withheld their final investigation documents in full, citing privacy protections under the Official Information Act.
The Medical Council of New Zealand subsequently requested and received the Police investigation file.
They have declined to disclose to Voice For Life information about its consideration of the doctor's conduct or any resulting findings, decisions, documents or disciplinary action.
As of September 2026, the Ministry of Health confirmed that it did not consider the matter closed.
How the incident was discovered
Health New Zealand's internal chronology reveals how the incident came to the attention of officials.
At 10.28am on the day after the assisted death, a Principal Clinical Advisor emailed the attending doctor because the patient's euthanasia application was still recorded as being at the “arrangements underway” stage.
The advisor requested an updated date-and-time form and prescription so the application could be sent to the Registrar for its compliance review.
The doctor emailed back advising that the euthanasia death occurred the previous day, that they had received the euthanasia drug kit and uploaded the death certificate (which includes the cause of death) to the official electronic system.
The advisor began checking the records.
At 2.30pm, the advisor confirmed that colleagues had not received communication concerning the case.
At 3.30pm, checks established that there was no duplication of records in the government assisted-dying information system.
Then, at 3.40pm, the dispensing pharmacy confirmed that it had no prescription for a lethal drug kit for the deceased patient.
The pharmacist also advised that a lethal drug kit supplied the previous November had not been returned.
Twenty minutes later, at 4pm, the matter was escalated to the manager of Health New Zealand's Autonomy Team, which oversees aspects of the assisted-dying service, triggering a series of reports and reviews.
The internal investigation subsequently established that the previously unused lethal drugs had been used to end the life of the second patient without the mandatory legally-required review.
A mandatory legal safeguard bypassed
The fact that the doctor could, and did, bypass the legally required Registrar review before administering a lethal dose of drugs to a patient raises serious questions about the so-called 'safeguards' in the NZ euthanasia system.
Under the End of Life Choice Act, the Registrar’s role includes receiving required forms from doctors and checking they have complied with necessary legal processes before an assisted death can take place. The Ministry of Health says this is “an essential safeguard in the process”.
Among other things, the forms record what practitioners told the patient about their prognosis, their efforts to ensure the patient is not being pressured by others, and whether they think the patient is eligible for assisted dying and competent to make that choice.
The Registrar must be satisfied that the required processes have been followed and notify the attending medical practitioner before the administration of lethal drugs can proceed.
The intention of the Registrar's check, according to the Ministry of Health, is to provide a critical safeguard — both for people accessing euthanasia and assisted suicide and for practitioners carrying out the act.
The doctor's failure to comply with this legal requirement, the fact that the breach was only discovered after the patient's death, and the subsequent decision by Police not to lay charges raise serious questions about the system's ability to detect noncompliance and hold practitioners accountable.
Investigation exposes widespread failures to return assisted-dying drugs
Health New Zealand's investigation into the incident exposed serious, wider problems with the monitoring and reconciliation of assisted-dying drugs, lethal drug expiry dates, the storage of unused lethal drugs, and the procedures governing their return.
It also found that the service had no formal standard requiring lethal drug kits to be returned within 14 days, despite this being the expected timeframe, and that unused lethal drugs could remain accessible without overdue returns being identified and escalated. These are pharmaceutical products specifically supplied to end lives.
A six-month lethal drug audit examined by Health New Zealand following in its review of the 2024 incident found that only 13.5% of lethal drug kits from one dispensing pharmacy and 33.59% from the other were returned within 14 days.
That meant the overwhelming majority of kits examined in that audit were not being returned within the expected timeframe.
A separate audit revealed particularly lengthy delays. For one dispensing pharmacy, late returns ranged from 15 to 210 days after dispensing. At the other pharmacy, they ranged from 15 to 59 days.
The findings were particularly concerning given the circumstances of the euthanasia under investigation, in which lethal drugs originally supplied for another patient had remained in a clinical setting for more than eight weeks before being administered.
Following the incident and subsequent review, Health New Zealand introduced changes to its pharmaceutical management procedures, including stronger monitoring of lethal drug returns, monthly compliance reporting and new escalation processes for overdue lethal drug kit.
Further drug audits released to Voice For Life showed that compliance rates subsequently improved. However, even after changes to lethal drug monitoring began, substantial numbers of kits continued to be returned outside the expected timeframe.
In an audit covering January to June 2026, involving 341 lethal drug kits, compliance had improved to 82.11%. Nevertheless, 61 late returns were recorded, including eight exceeding 30 days.
Health New Zealand introduces changes following the incident
Health New Zealand also confirmed changes to assisted-dying clinical guidelines and operational documentation, alongside the introduction of a new integrated digital system.
According to Health New Zealand, the system includes mandatory controls intended to prevent lethal drug kits from being released to dispensing pharmacies without the required compliance review.
Health New Zealand says the changes have strengthened oversight, accountability and compliance with lethal drug-management requirements.
However, the documents supplied to Voice For Life do not establish whether the new safeguards have been independently tested or evaluated for their ability to prevent or detect a similar breach.
Crucially, the new digital controls are designed to prevent lethal drug prescriptions being released without the required review. But the doctor in this case did not obtain a new prescription. They used a lethal drug kit already in their possession, originally prescribed for another patient.
The question, therefore, is not simply whether Health New Zealand has improved its procedures. It is whether the system can now prevent a doctor from acting outside those procedures — or reliably detect when they have.
Until that can be demonstrated, the possibility of another euthanasia occurring outside the safeguards required by law remains a very real possibility.
Voice For Life: When the law is broken, the consequences are irreversible
For Voice For Life, this case exposes one of the fundamental flaws about legalised euthanasia: the consequences of failing to follow the law cannot be undone.
The investigation raises serious questions about how medical practitioners are held accountable, how lethal drugs are monitored once dispensed, and how easily legal safeguards can be bypassed.
Concerns extend beyond procedural compliance.
The euthanasia system places significant responsibility on individual doctors to assess eligibility, identify potential coercion and determine whether a patient's request for euthanasia or assisted suicide is genuinely informed and voluntary.
“This case should deeply concern every New Zealander,” Voice For Life president Lydia Posthuma says.
“A doctor was able to carry out euthanasia without the legally required review, using expired lethal drugs prescribed for someone else, and the system only discovered what had happened after the patient was dead.
“If safeguards can be bypassed and serious breaches are only discovered after a patient had their life ended, then surely this demonstrates that legalising euthanasia has created new risks to vulnerable people that cannot be safeguarded against?”
These questions are particularly significant as New Zealand considers proposals to expand eligibility for euthanasia and assisted suicide. If more people become eligible and the number of cases increases, the risk of even more illegal acts being used by those ending patient lives will worsen.
“Every New Zealander deserves excellent, genuinely safe, compassionate and dignified end-of-life care — not exposure to a system that cannot guarantee even its most fundamental safeguards will be followed,” Posthuma says.
This investigation is based on official documents obtained by Voice For Life through information requests to Health New Zealand, the Ministry of Health, New Zealand Police and the Health and Disability Commissioner, together with correspondence from the Medical Council of New Zealand.