Statutory Committee

Reprimand for pharmacist in “unusual case”
Superintendent reprimanded after returned drugs dispensed
Decision on application for registration postponed
Drugs theft leads to striking-off order
“Astonishing chain of errors” leads to reprimands

Reprimand for pharmacist in “unusual case”

Events following his failure to notify the Society of his resignation as superintendent pharmacist of a company led to a pharmacist being reprimanded by the Statutory Committee.

At its meetings on September 20 and October 10, 2000, the committee inquired into the case of Mr Andrew James Baker, of Chamber 5, Fountain Court, Steelhouse Lane, Birmingham. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging (i) that, as superintendent pharmacist, Mr Baker had failed to perform his duties properly with the result that an unsupervised sale of a pharmacy medicine had been made to one of the Society's inspectors on January 23, 1999, and (ii) that the business had traded without a pharmacist in charge on January 18, 19, 21 and 22, 1999. It was further alleged that Mr Baker had delegated his responsibilities as superintendent pharmacist to a person whose name had been removed from the register for misconduct. Alternatively, it was alleged that, if Mr Baker had resigned as superintendent pharmacist he had acted unprofessionally in failing to notify the Society of that fact. A final allegation was that Mr Baker had made an untrue or misleading statement in a letter to the Society dated April 3, 1999, claiming to have resigned as superintendent at Christmas, 1997, when he had confirmed in a letter dated January 12, 1998, that he accepted the responsibilities of that position.

Mr D. Bradly, of counsel, instructed by Pennington's (solicitors), appeared in order to present the facts of the case to the committee.

Mr Baker, who is a barrister as well as a pharmacist, represented himself at the hearing.

The committee heard that on November 19, 1997, Mr Baker had been appointed superintendent pharmacist of Eastrop Analytical Services, a company that operated the Buckskin Pharmacy, 3 Buckskin Centre, Buckskin, Basingstoke. The company had been set up by Mr Geoffrey Whitechurch, a pharmacist whose name had been removed from the register the previous day. Mr Baker, at the time a friend of Mr Whitechurch, and who had handled his unsuccessful appeal against striking off, had said he intended to take the appointment for a short time only.

On January 23, 1999, two of the Society's inspectors had visited the pharmacy and purchased pharmacy medicines when no pharmacist had been present. Mr Whitechurch, a director of the company, was present. He had told the inspectors that no pharmacist had been on the premises on January 18, 19, 21 and 22 when a total of 266 prescriptions had been dispensed, that he was responsible for booking locums and that Mr Baker, the superintendent pharmacist, would not know what pharmacist cover was in place on a particular day. He also told the inspectors that he had not spoken to Mr Baker for “three or four months”.

Interviewed on the same day, Mr Baker had denied that he was still the superintendent pharmacist, having resigned in the spring or summer of 1998. He said he had not notified the Society at the time, but had asked the company to do so. He had actually written to inform the Society of his resignation on March 28, 1999.

Curious

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said it was an unusual case. There was no dispute about Mr Baker's appointment as superintendent pharmacist. That appointment had come about in a curious way. As a barrister, Mr Baker had acted without charge for Mr Whitechurch in his appeal against the committee's striking-off order. Immediately it was known that the appeal had failed, Mr Baker had offered to take on the duties of superintendent pharmacist. Mr Baker had told the committee that he intended to take the post only for a short time, “until Christmas at the latest”. Following his appointment, Mr Baker had acted as an effective and responsible superintendent for several weeks. However, on January 12, 1998, Mr Baker had signed the Society's standard letter accepting the responsibilities of a superintendent pharmacist. He had explained that he regarded the form as no more than a bureaucratic requirement he had to comply with. That strained the committee's credulity, said the chairman.

Turning to the question of whether or not Mr Baker was still superintendent pharmacist in January, 1999, the committee felt that, although it was most unsatisfactory that Mr Baker had not informed the Society of his resignation, it would not be a reasonable conclusion that he was still superintendent at that time. The facts pointed to his position having come to an end in late spring or summer of 1998.

The chairman noted that although there was no legal obligation on a pharmacist giving up an appointment as superintendent pharmacist to inform the Society, the form for “Notification of a new superintendent” emphasised the advice that such notification should be made immediately, giving the date of resignation.

There was no specific incident in the first half of 1998 when it might be said that the standards of efficiency and quality of pharmaceutical services had not been met. But it was not acceptable that a superintendent pharmacist had failed to attend to his professional responsibilities over a period of months. It should have been appreciated by Mr Baker that, in this particular pharmacy's circumstances, the Society would have been concerned to know, in the public interest, whether a superintendent pharmacist remained in post. At the very least, he had the professional responsibility to correct the Society's understanding of his role in relation to the pharmacy as soon as possible.

The committee found Mr Baker guilty of professional misconduct. However, it considered that his original involvement had come about from his wish to help a friend, he had received nothing for it and could claim to have been let down badly. Rather than striking him off, the committee ordered that Mr Baker should be reprimanded.

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Superintendent reprimanded after returned drugs dispensed

AHampshire superintendent pharmacist whose pharmacy had dispensed medicines returned for destruction has been reprimanded by the Statutory Committee.

At its meeting on September 19, the committee inquired into the case of Mr Ashok Kumar Rishi, of 50 Faversham Avenue, Queens Park, Bournemouth, Dorset. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that effective systems had not been in place at his pharmacy to ensure that the pharmaceutical services provided were to acceptable standards.

It was alleged that that might amount to misconduct which rendered Mr Rishi unfit to have his name on the pharmaceutical register.

Mr D. Bradly, of counsel, instructed by Penningtons (solicitors), appeared in order to place the facts of the case.

Mr Rishi was present at the inquiry and was represented by Ms Joanna Glynn, of counsel, instructed by Brook Oliver (solicitors).

The committee heard that Mr Rishi was superintendent pharmacist of Orbitsure Ltd, which at the relevant time owned A. K. Rishi Pharmacy, 3 Station Road, New Milton, Hampshire. In April, 1998, a patient had returned to the pharmacy for destruction about 100 boxes each of 25 tablets of hydrocortisone 10mg. The tablets had been dispensed and labelled in France, but as they had since been subject to high ambient temperatures, the patient had doubts about their efficacy and had been advised that they should be disposed of.

The following month, the same patient had presented at Mr Rishi's pharmacy a prescription for 100 fludrocortisone 0.1mg tablets and 300 hydrocortisone 10mg tablets. When he received them, the patient identified the hydrocortisone tablets as some of those he had previously returned for destruction. They had been made by Roussel (whereas MSD tablets were usually dispensed for him in Britain), they carried the same expiry date, the writing on the packaging and the package insert was in French, and part of the label bearing the social security number and price had been removed (as was the practice in France).

When interviewed by one of the Society's inspectors on October 23, 1998, Mr Rishi had admitted having supplied the patient with some of his own medicine. He said that there was a procedure in place for dealing with returned medicines, involving a bin for the disposal of unwanted medicines. Although it was not written down, staff were aware of that procedure. In this instance, however, for reasons he could not explain, it had not been followed. The returned hydrocortisone tablets, it appeared, had been placed in the pharmacy's computer room and some had been redispensed.

The committee was also told that on October 14, 1998, when Mr Rishi was in charge of the pharmacy, domperidone liquid had been wrongly supplied on a prescription calling for droperidol. When the error had been discovered later in the day, one of the pharmacy staff had telephoned the home for people with special needs at which the patient was resident, and to which the prescription had been delivered and notified staff there of the error. The correct medicine was sent to the home by taxi the same evening and handed over to a patient. The patient was seen with the medicine by one of the home's staff, who took custody of it. The taxi driver refused to collect the wrongly dispensed domperidone, which thus remained, wrongly labelled, at the home.

Concerns about the level of work at the pharmacy had previously been discussed with Mr Rishi by the Society's inspectors.

In answer to questions, Mr Rishi said his pharmacy (which had since been sold) had dispensed about 15,000 prescriptions a month, employed several other pharmacists, six full-time dispensers and 42 trained pharmacy staff. There were usually two pharmacists on duty.

Extensive references, in person and in writing, were produced on Mr Rishi's behalf.

Serious

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said that, of the two incidents before them, the first was significantly more serious and the facts were not disputed. Had the returned tablets been supplied to another member of the public, commented the chairman, real damage or injury might have been caused. It was startling that those tablets had been left in an office in a corner of the pharmacy for almost a month. Mr Rishi might not have been the individual who had placed them there, but as superintendent pharmacist it was his responsibility to know what was going on in the premises and to ensure that proper systems were in place.

The committee could not reach a conclusion as to whether the tablets had been taken from the office in innocent error or otherwise; there was no evidence either way. Clearly, however, one of the dispensing team or one of the pharmacists had had access to them and had redispensed them. That was a serious matter and that incident amounted to misconduct.

In the second incident, involving an incorrectly dispensed prescription, the error had been discovered quickly and Mr Rishi had taken steps immediately to inform the home and for the correct medicine to be delivered. He had indicated that he expected the wrongly dispensed medicine to be retrieved and returned to the pharmacy. However, when that did not happen, Mr Rishi had taken no steps to ascertain where that medicine had ended up for the evening. He had therefore only partly arranged for the task to be completed.

Although that incident itself was not so serious as to render Mr Rishi unfit to be on the register, taking the two together the committee concluded that misconduct had been established of such seriousness as to render Mr Rishi unfit to be on the register.

However, fulsome references had been provided in Mr Rishi's favour and it was 1995 since there had previously been any misconduct (resulting from a dispensing error), for which he had received a written reprimand.

The committee decided that Mr Rishi should be reprimanded.

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Decision on application for registration postponed

An overseas pharmacist's application to be registered with the Royal Pharmaceutical Society should not be considered for at least 12 months, the Statutory Committee has decided.

At its meeting on August 15, 2000, the committee inquired into the case of Mr Asim A. Zarroug, a Sudanese graduate who had applied to be registered as a pharmacist in Great Britain. Information had been received that at Marylebone magistrates court on July 27, 1997, Mr Zarroug had pleaded guilty to four offences of submitting false claims for state benefit, stating that he had been unemployed when he had been working, and had asked for 28 similar offences to be taken into account.

For those offences he had been sentenced to 120 hours of community service and ordered to pay £75 costs and £2,717 compensation.

Mr G. R. F. Hudson, of Pennington's (solicitors), appeared in order to present the facts of the case to the committee.

Mr Zarroug was present at the inquiry and was represented by Mr David Reissner, of Charles Russell (solicitors).

The committee heard that Mr Zarroug had gained an MSc in the USSR in 1986. He had then returned to the Sudan and practised as a pharmacist there until 1990, when he came to Britain. He had been granted refugee status in 1993.

He obtained an MSc in pharmaceutical technology from the University of London in 1994. He then applied for registration with the Society but the application was refused.

In 1998, after an appeal, he was told that his application could proceed, subject to his taking the one-year “return to practice” course at Sunderland University and passing the overseas pharmacists' examination, then completing 12 months' approved employment and passing the Society's registration examination.

The offences had come to light when, after passing the overseas pharmacists' examination in July, 1999, Mr Zarroug had applied for approved employment and, as he was required to do, notified the Society of his convictions. He had been advised that he could take up preregistration training but it had been made clear that the Statutory Committee would have to take those convictions into consideration when considering whether or not he would be allowed to register.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said that over a period of two years, Mr Zarroug had defrauded the Department of Social Security, falsely claiming benefits for housing and income support amounting to £5,458. The amount falsely claimed had been repaid and although initially he had not admitted the offences, Mr Zarroug had made a clean breast of the matter before the case had come to court.

The committee recognised that Mr Zarroug had been under pressure in his personal life and his financial affairs. It was also noted that his extended period of community service had been completed satisfactorily. And he had indicated his deep shame about the offences.

Noting that he had been unsuccessful when he sat the registration examination, the committee directed that no application for Mr Zarroug's name to be registered should be considered for at least 12 months. There would thus be an opportunity for him to discover whether he could pass the Society's examination, added the chairman.

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Drugs theft leads to striking-off order

Apharmacist who had stolen drugs from his employers has had his name removed from the register by the Statutory Committee.

At its meeting on October 12, 2000, the committee inquired into the case of Mr David Michael Hardman, of 105 Bramble Lane, Mansfield, Nottinghamshire. Information had been received that on December 2, 1999, at Sheffield magistrates' court, Mr Hardman had pleaded guilty to stealing, on July 2, 1999, 100 dihydrocodeine tablets, eight Robaxin (methocarbamol) tablets and 200 codeine phosphate tablets belonging to his employer. He had also pleaded guilty to stealing from his employer, between February 1, 1998, and July 2, 1999, dihydrocodeine tablets, codeine phosphate tablets, nitrazepam tablets and Robaxin tablets. For those offences, he had received 12 months probation, and ordered to serve 100 hours of community service and to pay costs of £55.

Mr G. F. R. Hudson, of Pennington's (solicitors), appeared in order to place the facts of the case before the committee.

Mr Hardman was present at the hearing and was represented by Mr S. Flew, of Le Brasseur J. Tickle (solicitors).

The committee was told that the offences had come to light when his area manager had checked the computerised patient medical records of the pharmacy of which Mr Hardman had been in charge and discovered a record for the supply of Seroxat (paroxetine) for which no prescription had been submitted to the Prescription Pricing Authority. Mr Hardman had been questioned and had produced from his briefcase a container with 100 dihydrocodeine tablets and a bottle with eight Robaxin. The police had been informed and interviewed Mr Hardman, who had admitted having been addicted to codeine phosphate, and told the police there were more tablets at his home, including codeine phosphate and nitrazepam. He said he had taken Seroxat tablets for his girlfriend but had not brought the prescription to the pharmacy. He also said he had treated himself with Prozac for a long period.

Health support

Shortly after his arrest, he had been in contact with the Pharmacists' Health Support Scheme and been referred to Birdsgrove House; he had been free of drugs since then and his prognosis was said to be good. References were produced from his probation officer, an employer and the co-ordinator of the health support programme.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said they accepted that there was no personal gain for Mr Hardman and there was no evidence that he had taken the drugs to supply to others. He had co-operated with the police and pleaded guilty when the matter came to court. However, he had seriously breached the trust of his employers and the pharmacists' Code of Ethics. The committee could not treat his addiction to the drugs in question only as a health issue. His misconduct had been proved by the convictions and the committee directed that Mr Hardman's name should be removed from the register.

The chairman added that there was no reason for Mr Hardman to believe that there would be no opportunity for him to return to the register in due course. If he sought restoration he would have to be able to demonstrate that he had maintained the progress he had made .

Mr Hardman had three months in which to appeal against the committee's decision.

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“Astonishing chain of errors” leads to reprimands

Three pharmacists were reprimanded by the Statutory Committee after an “astonishing chain of errors” led to used injections that had been returned for disposal being dispensed for another patient.

At its meeting on October 10, 2000, the committee inquired into the cases of Gylla Ltd, a company that owned two pharmacies — St Mary's Pharmacy and Barn Surgery Pharmacy in Gillingham, Dorset — and Mr Antony Vincent Johnson (of “Acorns”, The Street, Motcombe, Shaftesbury, Dorset), Mrs Sheila Margaret Daxter (of St Mary's Pharmacy, The Square, Gillingham, Dorset), and Mrs Sheila Davis (of 2 Bridge Close, Gillingham, Dorset). Mrs Daxter was the superintendent pharmacist of Gylla Ltd and Mr Johnson a director of the company.

Allegations

Information had been received from the Council of the Royal Pharmaceutical Society alleging:

• The absence in St Mary's Pharmacy prior to July 7, 1999, of adequate systems to ensure that medicines returned from patients were not placed in dispensary drawers; and/or
• The repackaging at St Mary's Pharmacy on or about February 5, 1999, of medicines returned from a patient for use in dispensing to another patient at Barn Surgery Pharmacy; and/or
• The dispensing to a patient at Barn Surgery Pharmacy between about February 5 and 10, 1999, of medicines returned from another patient; and/or
• The failure between February 26, 1999, and July 7, 1999, to make effective checks at St Mary's Pharmacy to ensure that no medicines returned from patients were present in the dispensary drawers of that pharmacy

It was alleged that those actions might demonstrate such misconduct as to render the company and the pharmacists unfit to have their names on the register.

Mr G. F. R. Hudson, of Pennington's (solicitors), appeared in order to place the facts of the case to the committee.

Mr M. Aaronberg, of counsel, instructed by Charles Russell (solicitors), appeared on behalf of the company and of Mr Johnson, Mrs Davis and Mrs Daxter, who were all present.

The committee heard that, in February, 1999, a patient had presented a script calling for four 0.5ml prefilled syringes containing dalteparin 25,000iu per ml at Barn Surgery Pharmacy. There was none in stock and Mr Johnson, the pharmacist in charge, had contacted Mrs Davis, the pharmacist at St Mary's Pharmacy and asked her to send him eight dalteparin syringes. Mrs Davis had put eight syringes from a manufacturer's box in a skillet, labelled it and sent it to Barn Surgery Pharmacy. Mr Johnson received the skillet, saw the label but did not check the contents and relabelled the box which was subsequently collected by the patient.

The dalteparin injections were taken to be administered by the practice nurses at Barn Surgery. Two had been given on consecutive days, but when the patient returned for a third injection, another nurse was present and noticed that the syringes in the box were almost empty and appeared to have been used.

It transpired that the syringes were some that had been returned to Barn Surgery Pharmacy for disposal after use by another patient and had been transferred to St Mary's Pharmacy.

The patient did not complain to the Society until June and an inspector had visited the prescribing doctor on July 7, subsequently visiting Barn Surgery Pharmacy. While there, the inspector had found several items returned from other pharmacies mixed in a drawer with dispensing stock.

Interviewed

When Mrs Davis had been interviewed, she had said that she was unfamiliar with the packaging of dalteparin syringes and had been unaware that the original containers contained blister packs of five syringes.

Mrs Daxter, the superintendent pharmacist, had been unable to explain how the syringes had come to be in the dispensary at St Mary's Pharmacy. She said a written protocol for dealing with returned medicines had now been implemented.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said the dispensing of the previously used syringes could have had had a very serious outcome for the patient. As it was, she had been extremely distressed and anxious that she might have picked up some infection from the syringes.

It had been an astonishing chain of errors. It began when the syringes had been moved from one pharmacy to the other, when they were put in a wrong drawer and when Mrs Davis had put them in a skillet without checking that there was any liquid in them, and when Mr Johnson had failed to check the contents of the skillet. Clearly, there had been serious errors and flaws in the systems in place in the two pharmacies and Mrs Daxter, as superintendent pharmacist, had to carry the responsibility for that.

The matter did not end there. When the inspector had called in July and looked in the self-same drawer in the dispensary he had found four boxes containing injectables bearing labels showing that they had been dispensed elsewhere. Mrs Daxter had admitted misconduct in the absence of adequate systems to ensure medicines returned from patients were not placed in dispensary drawers and failing to make effective checks between February and July, 1999, to ensure that no returned medicines were in the drawers.

That amounted to serious misconduct such as would render her liable to be removed from the register.

Mrs Davis had admitted repackaging the eight syringes for use by the Barn Surgery Pharmacy, and that demonstrated that she had been guilty of misconduct such as to render her unfit to have her name on the register.

Mr Johnson had admitted his failure to check the contents of the skillet he had supplied and that amounted to misconduct such as to render him liable to have his name removed from the register. However, the inspector had noted there had been significant improvements in the systems in place at the pharmacy; he would further review the systems over the coming months.

The committee ordered that Mrs Daxter, Mrs Davis and Mr Johnson should be reprimanded. No order was made against the company.

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