South Australian coroner Emma Roper is inquiring into the death of Pelayo Del Carmen Cortes Godoy, 82, a Chilean miner who migrated to Australia with his wife Rosa in 1985.
Counsel assisting Greg Dudzinski told the court Mr Cortes, who had minimal vision in his right eye and lost his left eye in a crash, relied on his wife to collect his seven prescribed medications from Chemist Warehouse Parabanks in Salisbury, in Adelaide's north.
The couple both spoke limited English and relied on their children as interpreters in relation to Mr Cortes' health.
On May 15, 2020, Mrs Cortes collected medication for herself and her husband from the pharmacy.
"One of the Webster-paks ... had Mr Cortes' details on the front … however, the rear of the pack had the name of Andrew Cummings, his address and a list of medication prescribed to him," Mr Dudzinski said on Tuesday.
Mr Cortes consumed medication from the pack on May 18 and the following day complained to his wife he was unwell.
A locum doctor who examined him observed the two Webster-paks contained different medication and each was labelled with different names.
Mr Cortes was rushed to Lyell McEwin Hospital but his condition deteriorated rapidly and he died the following day.
A forensic pathologist concluded that the cause of death was aspiration pneumonitis and cardiac arrest, following accidental polypharmacy overdose.
The primary focus of the inquest would be factors that led to the supply of incorrect medication, which was packed at another pharmacy in the same suburb, Mr Dudzinski said.
Lawyer Chad Jacobi KC said his client Eric Cheng - who was a proprietor at the pharmacies where the medication was prepared and dispensed - wanted to apologise to Mr Cortes' family.
Mr Cheng, who will give evidence on Thursday, "has asked that I publicly apologise to each member of Mr Cortes' family for the errors that were apparently made at the pharmacies", Mr Jacobi said.
"And for his regret at the loss of Mr Cortes and the grief and the suffering … to the family."
The inquest would also focus on whether relevant policies and procedures had been followed, and if the supplying pharmacist Kin Long Lee should have thoroughly checked the packs before giving them to Mrs Cortes.
In evidence, Mr Lee agreed that he had noticed that one of the Webster-paks in Mr Cortes' bundle was labelled on the back with the name Adrian Cummings.
"I went to the shelf, checked the Adrian Cummings bundle, and then realised the same problem happened as well ... and swapped the packs at that time," he said.
The pharmacist acknowledged making a mistake.
The inquest continues.
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