Two pharmacist brothers who allowed the unsupervised sale of pharmacy medicines in one of several pharmacies they owned in partnership have been reprimanded by the Statutory Committee. In addition, a pharmacist who had managed one of their pharmacies has been reprimanded over a series of dispensing errors in medicines prescribed for residents of a nursing home.
The case concerned Mr Anil Paul Khanna and Mr Sunil Paul Khanna, both of 40 St Georges Terrace, Jesmond, Newcastle upon Tyne, and Mr John David Percival, of 5 Tosson Terrace, Heaton, Newcastle upon Tyne.
The committee made its decisions in the course of an inquiry that began on February 17 and 18, 1998. After giving its decision in the case of Mr Percival, the inquiry was adjourned to January 21, 1999. Further hearings took place on May 18 and 19, 1999, when the committee administered its reprimand to the Khanna brothers and dismissed an additional complaint relating to an alleged dispensing error.
Mr M. Seligman, of counsel, instructed by Walker Martineau (solicitors) appeared at all three hearings in order to place the facts of the case before the Committee.
The Khanna brothers were present at all three hearings and were represented by Mr T. Spain, of counsel, instructed by Singleton Winn & McDermot (solicitors).
Mr Percival was present, accompanied by his father, on February 17 and 18, 1998.
At the initial hearing the Committee was told that the Khanna brothers had, at the relevant time, jointly owned three pharmacies trading as Medicentre Chemists, including one at 41-47 St Georges Terrace, Jesmond, where Mr Percival had been manager. The brothers had also been directors of a company, Medicentre Ltd, which owned a pharmacy at 132-136 Elswick Road, Newcastle upon Tyne. Mr A. P. Khanna had been the company's superintendent pharmacist.
The committee heard that the Council of the Royal Pharmaceutical Society had made two complaints. The first had arisen from a special investigation into a large number of dispensing errors in a delivery of dispensed medicines from the pharmacy at St Georges Terrace to a residential home in March, 1996. One error was the supply of a bottle labelled as containing carbamazepine syrup but subsequently identified as containing Epilim (sodium valproate).
The remaining errors all related to products dispensed into Manrex-type monitored dosage system packaging. The MDS trays had been assembled in the Medicentre Ltd pharmacy for dispensing from St Georges Terrace. Several of the errors related to supplies labelled inadequately or with wrong dosages. One was a supply labelled with the name of a patient who had not been prescribed the product. Another was a supply of tablets labelled as aspirin that were later established to be isosorbide mononitrate tablets.
The facts of the case suggested, said the Council, that the systems in place for the supply of prepacked medicines from one pharmacy to the other were unsafe and/or that the pressure of work allowed insufficient time to dispense and check the medicines adequately and/or that there was a failure to check adequately the medicines before delivery and/or that dispensed medicines were delivered while doubts remained about them. This, the Council alleged, amounted to misconduct by the Khanna brothers and Mr Percival.
The Council's second complaint was that on March 18, 1997, at Newcastle upon Tyne magistrates' court, the Khanna brothers had each pleaded guilty to and been convicted of three offences of allowing the sale of medicines not on a general sale list, the sales not being made by or under the supervision of a pharmacist. Each had been fined a total of £1,500 and ordered to pay costs of £1,737.36.
The committee heard that the Khanna brothers had appeared before the committee on two previous occasions. An inquiry in 1989 had resulted in an admonition for each brother and one in 1991 had resulted in a reprimand for each.
In regard to the dispensing errors, the committee heard that in March, 1996, Mr Percival had returned from holiday shortly before the Jesmond pharmacy was due to make a supply of medicines to a nursing and residential home with about 45 patients. Although before leaving he had given instructions as to how the medicines were to be prepared, he had found on his return that his instructions had not been carried out sufficiently. Not only that, but he had been left with only three days instead of the usual six to get all the medicines in order. For that particular home there would about 250 prescriptions to be sorted through in three days, amid the dispensing of prescription for members of the public.
Under pressure, Mr Percival had decided to let the medicines leave the pharmacy. He had intended to check them during a visit to the home on the following day. However, the home's nursing sister had discovered the errors and had initiated a complaint.
Giving the committee's decision at the end of the February, 1998, hearing, the chairman (Mr Gary Flather, QC) said that the committee's primary concern in the case was to do with the Khanna brothers. It was a case either of procedures not being explained to the staff or of the brothers not ensuring that the staff understood the procedures explained to them. The brothers accepted that at the end of the day they were liable for everything their staff did.
The chairman said that he would later be going into the "extraordinarily extensive" steps taken by the brothers to ensure that mistakes such as unsupervised sales did not occur again. But those steps were also aimed at preventing the "near catastrophic" situation that had arisen in March, 1996, which all three pharmacists deeply regretted.
So far as Mr Percival was concerned, the committee accepted in mitigation the fact that, having registered only in 1994, he lacked experience, or maturity, and could not cope with the stress as well as somebody of greater maturity. He had now almost certainly learnt that when he got himself into such a tight situation he had to seek help and not send out the medicines until satisfied that they had been sufficiently checked.
Even though the committee accepted Mr Percival's defence that he was not to blame for all the mistakes, an unacceptably large number remained. However, he was now superintendent of a pharmacy elsewhere and his future should not be ruined by "that dreadful delivery". The committee therefore reprimanded Mr Percival.
Turning to the Khanna brothers, the chairman said that in March, 1996, there had been no reason for them to think that Mr Percival was not able to do what he should have done. There had been no reason to think that he would make the misjudgment that he did of sending out the medicines without fully checking them.
The chairman went on to say that what was noticeable about the Khanna brothers was their enthusiasm and keenness. They were building up their own business with commendable zeal and they had impressed the committee with evidence of the steps that they had taken to reduce the likelihood of mistakes happening again.
They had, for example, invested heavily in improving the Jesmond Road pharmacy. Photographs had shown a professional outlet - clean, well run conditions. They had some 50 employees in their four branches. They had produced a staff manual setting out what everyone had to do and every consideration everyone ought to bear in mind. They sent their employees on training courses and had fortnightly training meetings. They now served nine residential homes, bringing in about 1,000 prescriptions a month.
This was not the moment, said the chairman, to look to the past and say that the mistake that occurred through Mr Percival should impede their future progress. So the committee was going to adjourn the case for a year and if there was nothing but good to report after that time, the brothers could expect a result that would allow them to continue to carry on as pharmacists.
When the inquiry resumed on January 21, 1999, the committee was told that the Society had received a new complaint in June, 1998, relating to an incident on March 17, 1998, at the Medicentre pharmacy in Elswick Road, Newcastle upon Tyne. The complainant had alleged that 60 thioridazine 100mg tablets, labelled "take two three times a day", had been dispensed against a prescription calling for metronidazole, and that, after taking two tablets, the patient had collapsed.
The Society alleged that the incident indicated a failure to comply with the staff manual that had been the subject of much of the committee's judgment in February, 1998, since the dispensing label had not been ticked as having been checked by the pharmacist in charge and the computerised patient medication record for that particular dispensing, when eventually found, had been inadequate and showed a breach of procedures. The Society further alleged that there had been a failure to deal with a subsequent complaint and that the subsequent disappearance of the prescription was also relevant.
The Society also alleged that inspections of all four pharmacies had shown a persistent non-compliance with four specific areas of procedure: recording complaints, checking dispensary labels, maintaining computer records, and checking that the staff had actually read the staff manual.
The committee heard that on July 15 and 16, 1998, Society inspectors investigating the alleged dispensing error had interviewed the Khanna brothers and the pharmacist who had been in charge of the Elswick Road premises on March 17, 1998. Mr Sunil Khanna had been unable to produce a PMR for the dispensing on March 17, even though one should have been produced by generation of the prescription label. He had said that none of the pharmacies backed up their computer records. He had at first been unable to produce a customer complaints book. Later he had produced a complaints book in which the last entry had been made in October, 1995, and a dispensing error record book that had never been used. At a later date he had produced a print-out of a PMR that was inadequate in that it did not bear all the information required for such a record.
The committee also heard that inspectors had visited all four pharmacies run by the Khanna brothers on January 18, 1999, shortly before the hearing. They had found that all the previously identified areas of non-compliance with the staff manual were continuing. In all four pharmacies, prescriptions awaiting collection had been found that had one or both boxes on the label unchecked. No pharmacy was backing up its computer records. No pharmacy had a staff manual present and some had other documents missing as well.
The committee was told that the Khanna brothers had used a central tape-streamer to back-up their computers but that it had not been in working order at the time of the visits. In regard to the missing documents, the committee heard that shortly before the visits the Khanna brothers' solicitor had collected staff manuals and other documents for use at the hearing.
When the inquiry reopened on May 18 and 19, the committee was informed that since the January hearing one of the Society's inspectors had made a total of seven further visits to the Khanna brothers' pharmacies. On visits in March, 1999, a considerable improvement had been found, and during visits in May, 1999, everything had seemed in order. All but one branch had a new computer and back-ups were being done daily within each branch.
Giving the committee's decision in regard to the complaint first considered in February, 1998, the chairman said that the committee had taken account of what had happened since that initial hearing. Having considered that the statutory criteria had been now met, the committee had decided to dispose of the case by way of a reprimand.
The committee then went on to consider the complaint about the alleged dispensing error. After hearing evidence, the committee decided that none of the allegations, whether or not they were proved, amounted to misconduct by the Khanna brothers. The committee therefore concluded that there was no case to answer on that particular complaint.
Pointing out that the hearing was the fifth time on which the Khanna brothers had appeared before the committee, the chairman said that they needed to be very careful about the way they conducted their pharmacies, because if another irregularity was proved at a further appearance before the committee, it would be difficult for the committee to deal with them leniently.