From Mr P. Walton, MRPharmS
SIR,-We have seen a preregistration trainee under the threat of a prison sentence for manslaughter for a mistake made in the year in which mistakes are meant to be ironed out, and a pharmacist under the same cloud for supervising the said trainee. I would very much like the Society to state how many similar errors have occurred during this year, without this tragic consequence. I know that several manufacturing errors have occurred with excessive chloroform in my time as a pharmacist, and with all their post manufacture checks, have been released to the public. I cannot remember any section 64 Medicines Act prosecutions in those cases, nor can I recall any court case when Calpol recently was subject to a manufacturing defect, potentially putting many infants at risk of a higher than recommended dose. When a well-known dispensing doctor wrongly continued to prescribe an anti-cancer drug, which resulted in a patient's death, there were no criminal proceedings at all. I know of no pharmacist who will say that they have not had mistakes leave their pharmacy. We have all done so.
In circumstances like this, I would have expected the Society to have been telling the public that the dispensing process is very safe, and with the best will in the world human fallibility will from time to time cause errors with tragic consequences. I would also expect it to be saying that whatever happens in any pharmacy, there are several people responsible. The order of responsibility is from the pharmacy company, that decides on staffing (consequently stress) levels, skill mix, dispensing protocols and strategy, through to the pharmacist who is ultimately responsible for what is issued. Any other staff involved in the dispensing process should not be held accountable; they are not the final arbiters of what goes on, and usually have very little power to alter anything they may disagree with. If an error similar to the Boots peppermint water incident had happened at my pharmacy, I would be telling the police and prosecutors, that my staff could not be responsible for the error. The buck stops with the pharmacist, ie, me. Most of my pharmacist friends think similarly with regard to responsibility.
We have had no feedback from the Society as to what factors made this event more prosecutable than the myriad of other errors within pharmacy. We urgently need this information. Should we, for instance, stop making extemporaneous preparations, or follow such an onerous checking procedure as to force us to stop this activity on economic grounds? Should we refuse to dispense any prescriptions for medicines that we know cause the most problems, or where there is a chance of a dangerous occurrence, such as prescriptions for warfarin or diamorphine? Should we stop making nostrums, which for many reasons will never be made commercially? Should we refuse to train postgraduate students without more supporting ancillary staff? Of course these measures would not prevent errors. With the huge number of modes of error inherent in the dispensing process, and the huge numbers of prescriptions dispensed, errors are inevitable, the consequences of which are unpredictable.
I do not know what powers the Society has to question the reasons why some cases of error are prosecuted and some not, and on what charge.
None of the above takes away my deep sympathy for the bereaved parents. I cannot think of anything worse than losing a child.
Philip Walton
Swinton, Manchester