The Chief Coroner has criticised Pharmac's communication skills after it failed to warn epilepsy patients about a change to their drug regime.
But she has also found there was no link between the drug switch and the deaths of six people.
The release of Judge Deborah Marshall's findings was supposed to bring families answers, but instead, it left them with more questions.
"My first response was 'absolute shocker'," Michelle Townes told Newshub.
In December 2019, her son Andre Maddock died after an epileptic seizure. He'd recently changed his anticonvulsant medication.
A change in Pharmac funding meant nearly 11,000 epilepsy patients had to switch their brand of anti-seizure drug Lamotrigine from the brands Lamictal or Arrow-Lamotrigine to Logem.
Maddock's death, and the deaths of five others, launched a coronial inquest. But Judge Deborah Marshall concluded: "The evidence does not clearly link the brand switch to the seizures that led to the deaths."
"I don't know how they get that outcome. That's it," says Townes.
The coroner couldn't rule out the switch for Maddock's cause of death but also blamed other factors.
"Mild chronic appendicitis and insomnia were parts of the cause of his death. That doesn't cause a person to die," says Townes.
"It cannot be anything else except a chemical that can do that to your body, as far as I'm concerned."
Maddock's partner Nadia Jooste insists it can only have been the drug.
"Only towards the end he started taking more of the new generic drug, and I think that's where we saw the decline in his health, and just in his ability to be him," she says.
Jo Oliver also feels without the brand change, her son Will would still be alive.
"Do I still feel? Yes, I do. But then, it's never going to be said yes or no because the coroner doesn't know. And so now we've just got to live with him in our hearts," she says.
Because the coroner was unable to find a clear link between the drug switch and the six deaths, she made no recommendations.
"It's almost like it's been put in the too-hard-basket. 'We're not going to dig a little bit deeper so I'm just going to name it as it is and not make any recommendations.' And I think that part is probably the part that hurt most of us," says Jooste.
The report did observe Pharmac's communication strategy was lacking, and a pamphlet supposed to be given to patients wasn't - and even if it was, it wouldn't have alerted them to the possibility of any adverse symptoms.
"Just him coming home with a sticker on the box saying the drug changed, I was like 'wait, did they give you any information?' and he said no," explains Jooste.
Oliver says doctors and pharmacists each felt it was the job of the other to inform the patient.
"A lot of the doctors didn't even know that there was a brand change until it came out in the media. So the communication between Pharmac, the pharmacists, and the doctors was not good at all," says Oliver.
Pharmac says it'll work with the Ministry of Health to improve how it shares brand change information.
"We acknowledge it's our responsibility to make sure that health professionals know about brand changes, and they have access to the information they need to give to patients," says Pharmac's director of operations Lisa Williams.
Both families agree the decision has been disappointing, but they're split on whether it's brought closure.
"You've got to move on, but you've got that memory of him. This coming to an end has given closure. Will, you can rest now, go to sleep, be part of me," says Oliver.
Meanwhile, Jooste wants specialist appointments before patients switch drugs and more access to neurologists.
"We're always going to be left with unanswered questions, but that would be something that could be done in the public view to make sure this doesn't happen to the next group of people when a drug change does happen."
