The tragic death of a three-week-old baby as a result of a mistake made in a pharmacy is a cause of reflection for the profession as a whole (p390). First, we should reflect on the feelings of the parents, recognise their grief and share their sorrow. Nothing can make up for the death of a child. Next we have to reflect on the feelings of the young people who perpetrated this mistake. They cannot have intended nor foreseen the result of their actions, the result of which will remain in their memories for the rest of their lives. Then we have to reflect on the details of the case in order to take the necessary steps to ensure that such a tragedy never happens again.
As Chester Crown Court heard last week, Matthew Young died after being given peppermint water prepared extemporaneously in a Boots pharmacy by a preregistration trainee. The formula was contained in a book that needed to be revised. One of the ingredients, double strength chloroform water, was no longer available and concentrated chloroform water had to be used instead. The label of the concentrated preparation bore no instructions for dilution. A dispenser told the trainee how to proceed, but had no further involvement. The measure which should have been used was broken. The trainee used too much concentrated chloroform water when making up the preparation. A pharmacist signed a check slip applied to the finished preparation, but did not inquire about how it had been made up. The approval of the premises for preregistration experience had lapsed.
All this makes grim reading and can only serve to undermine confidence in the profession. If pharmacists cannot be relied on to dispense medicines accurately, then who can be relied on in this field? And if pharmacists cannot be so relied on to perform this key task, how can they be relied on for anything else?
It is being pointed out that very little by way of extemporaneous dispensing is undertaken in pharmacies nowadays. This is undoubtedly true. But it should not be used as an excuse for poor standards. Rather, it should be a reason for setting up systems to manage the inevitable risk. Protocols should be established and calculations should be checked and checked again and recorded systematically. If there is any doubt, recheck. Single-handed pharmacists might even go so far as to institute a system of peer review with a neighbouring pharmacy.
Having made these comments, we recognise that the Boots company has done its best since Matthew's death to tighten up its systems, bringing special recording books into use. It has and is dealing with the case in an open manner so as to ensure that, not only the company, but suppliers and the profession as a whole learn all the necessary lessons.
The Society, too, is playing its part. Immediately after the death, it issued a warning that pharmacists should have proper procedures in place for extemporaneous preparations (PJ, May 30, 1998, p783). It is considering what further advice needs to be given to the profession and is examining the educational and professional standards issues arising from the case.
The formula for the peppermint water prescribed was that of Alder Hey children's hospital. The director of pharmacy at the hospital has pointed out the inadequacy of the labelling of concentrated products containing such ingredients as chloroform and peppermint (PJ, June 6, 1998, p824) and has expressed concern at a general lack of information about them. He made a number of recommendations on improving the knowledge of pharmacists and trainees, the labelling of concentrated products and the content of reference works. All should be pursued. And pharmacists generally should be looking at their practices and procedures to ensure that they are not found wanting.