The Society

Statutory Committee

Dispensing errors lead to striking off
No action follows unsupervised sales allegation
Reprimand for illegal hospice supply arrangement

Dispensing errors lead to striking off

A locum pharmacist who made serious dispensing errors has had his name struck from the Register of Pharmaceutical Chemists on the order of the Statutory Committee. The dispensing assistant in the pharmacy concerned was commended by the committee for her conduct in responding to “difficult circumstances”.

At its hearing on December 13, the committee inquired into the case of Mr Ronald Bergson, of Look Ahead Housing Association, Princess Beatrice House, 192 Finborough Road, London SW10.

Concern over conduct

A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that, while engaged as a locum pharmacist at a Plymouth pharmacy on January 24 and 25, 2000, Mr Bergson had arrived looking unkempt “as if he had been living rough”. His conduct on January 24 had given rise to concern among the pharmacy staff. He had talked to himself, had failed to answer questions, had appeared confused and had fallen asleep in the dispensary, so that he had had to be woken so that prescriptions could be dispensed. It was also alleged that he had made dispensing errors: on a prescription calling for methotrexate tablets, one weekly for 13 weeks, he had dispensed sufficient for one daily for 13 weeks; and on a prescription ordering the supply of 30 ml dexamphetamine elixir, he had supplied an almost full 500ml stock bottle. Other members of staff had corrected both errors.

Mr Geoff Hudson, of Penningtons (solicitors), appeared in order to place the facts of the case before the committee.

Mr Bergson was not present at the hearing and was not represented .

The committee heard from the superintendent pharmacist who had engaged Mr Bergson that he had interviewed him by telephone for a post as a long-term locum and he had seemed quite suitable. However, when Mr Bergson arrived to start work the superintendent had immediately noticed his unusual appearance and behaviour. The superintendent had introduced Mr Bergson to the pharmacy’s procedures, and while he was still in the pharmacy, the methotrexate prescription came in and he noticed Mr Bergson had dispensed 91 tablets instead of the 13 called for. He corrected the error before the prescription was handed out.

The superintendent had then had to leave the pharmacy on other business. Returning at 5pm, he had found his dispensing assistant “traumatised” by events during his absence. That evening, he had tried and failed to find another locum. The following day he had had to go to Glasgow and while there had been telephoned and told of the error with the dexamphetamine elixir; he had then instructed Mr Bergson to leave the premises.

The dispensing assistant at the pharmacy, Mrs Susan Deans, described how Mr Bergson’s behaviour had been difficult and unco-operative. Another pharmacist had come to the pharmacy to dispense some prescriptions, including that for 30ml dexamphetamine elixir, but when the patient came to collect it, Mr Bergson had gone to the Controlled Drugs cabinet, taken out the 500ml stock bottle of the elixir, written on the label and handed the bottle to the patient. Mrs Deans had followed the patient as she left the shop, retrieved the stock bottle she had been given, and had supplied her the correct medicine.

Illness problem

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC), said it appeared from the evidence that Mr Bergson did not have a problem with drugs or drink but, sadly, suffered from some mental illness. The committee had no hesitation in reaching the conclusion that the misconduct described was such as to render a pharmacist unfit to have his name on the register. Those were very serious matters and the public could have been put at real danger in relation to the dispensing errors. For that reason, the committee concluded that Mr Bergson’s name should be indeed removed from the register. Although the committee was aware of the underlying health problem, it did not find him guilty because of mental illness but because of his conduct while in the Plymouth pharmacy.

Mr Bergson was given three months in which to appeal against the decision

The chairman added that the committee wished to commend Mrs Deans for the way she had responded to an extremely difficult set of circumstances. It was because of her alertness that what might have been a catastrophic event, when a grossly excessive amount of drug might have been given to an addict, was avoided.

No action follows unsupervised sales allegation

The Statutory Committee decided to take no action in the case of a pharmacist who was the subject of an allegation that medicines had been sold at one of his pharmacies when no pharmacist was present.

At its meeting on December 12, 2000, the committee inquired into the case of Mr Saptal Singh Kalsi, of 32 St James Street, New Bradwell, Milton Keynes, Buckinghamshire. Mr Kalsi is the proprietor of two pharmacies, one at 67 Bedford Road, Marston Moretain, Bedford, the other at 32 St James Street, New Bradwell, Milton Keynes.

A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Kalsi had failed to ensure that sales of restricted medicines were not made in the absence of a pharmacist.

Mr Geoff Hudson, of Penningtons (solicitors), presented the facts of the case to the committee.

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

The committee heard that on June 24, 1999, at 1.16pm, one of the Society’s inspectors had purchased a pharmacy medicine, Clarityn, from the premises at Marston Moretain when no pharmacist had been present. The following day, another of the Society’s inspectors had purchased Day Nurse capsules and Solpadeine, at 1.23pm, and , HC45 cream at 2.04pm; on neither occasion had a pharmacist been present. The sales had been made by Mrs Kalsi, the wife of the proprietor.

On both those dates, the pharmacy had been kept under observation during the middle of the day. The locum pharmacist in personal control, Mr Sanjay Chopra, had been seen to leave the premises on several occasions for periods varying between six and 36 minutes. He had instructed the staff that medicines were not to be sold in his absence.

The committee was told that when he absented himself from the pharmacy, Mr Chopra was either sitting in his car parked some 20 yards away or was immediately outside, talking on his mobile phone; he had been sent a warning letter by the Society.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC), said the unusual feature of the case was that on the two days in question when the sales had been made, there was a locum pharmacist in personal control of the pharmacy. Although he had been outside the pharmacy, there was every indication that if called upon, he was immediately available. It had been argued for Mr Kalsi that, as there had been a pharmacist in personal control of the pharmacy, he had no case to answer. It was ,however, conceded that if the facts before the committee, of the sales in the absence of a pharmacist, had been brought before a criminal court under Section 52 of the Medicines Act, which is an offence involving strict liability, Mr Kalsi might well have been convicted. In that case, the matter could have been brought properly before the committee.

The committee concluded that no further action should be taken.

Reprimand for illegal hospice supply arrangement

A system for supplying medicines, including Controlled Drugs, to a hospice, although operated from good motives, was illegal and has led to a pharmacist being reprimanded by the Statutory Committee. No action was taken against the company the pharmacist worked for or its superintendent pharmacist.

At its meeting on December 14, 2000, the committee inquired into the case of E. Moss Ltd, Feltham, Middlesex, Mrs Caryl May Webb, of 14 The Oaks, West Byfleet, Weybridge, Surrey, and Mr Mohamed Abdullah Jeraj Jiwa, of 126 Porthdean Road, St Austell, Cornwall. Mrs Webb was the company’s superintendent pharmacist at the relevant time and Mr Jiwa was pharmacist in charge of the company’s branch at 3 Victoria Place, St Austell, Cornwall.

A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that the supply on or about January 19, 1999, of morphine sulphate solution without a labelled dosage, and temazepam tablets against a faxed order in the absence of a prescription authorising such supply, amounted to misconduct. It was further alleged that the system in use at the Moss pharmacy, St Austell, which involved the supply of prescription-only medicines, including Controlled Drugs, on the order of hospice staff and before prescriptions were received at the pharmacy, was inherently risk prone and illegal.

Mr Geoff Hudson, of Penningtons (solicitors), appeared in order to present the facts of the case to the committee.

Mrs Webb and Mr Jiwa were both present at the inquiry. They and the company were represented by Mr Philip Drinkwater, of counsel, instructed by Crosse & Crosse (solicitors).

The committee heard that the matter about which the complaints were made had come to light following the death of an elderly lady suffering from terminal cancer. The immediate cause of her death had been an overdose of morphine sulphate given to her by a nurse. That morphine sulphate had originally been dispensed by the Moss pharmacy in St Austell. It was of a higher strength than usual, 10 mg per ml. The bottle had not been labelled with the dose but the medicine had been accurately prepared and delivered at the strength required.

The system about which the complaints were made had been in use for about 20 years, when Mr Jiwa had been the pharmacist but before E. Moss had acquired the business. Staff of a local hospice would order medicines, including Controlled Drugs, before the prescriptions ordering the supply had been received by the pharmacy. Since the availability of fax machines, the orders had been given to the pharmacy in the form of a faxed copy of a page of an order book kept at the hospice; this recorded patients’ medicine requirements, but not the dose to be administered. The medicines would then be delivered. The patient’s doctor would, usually the same day, write a prescription for the drugs called for in the order book. The fax was sent in anticipation of a prescription being received.

Thus, the system entailed the dispensing of medicines, often Controlled Drugs, against a document that was not a prescription. Secondly, there was a risk that the doctor might not prescribe the medicine that had been ordered by the hospice staff and that the matter might not be put right before that medicine had been given to the patient.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that it should be made clear that the error resulting in the overdose being given was not because of any failing at the time the morphine sulphate was delivered to the hospice but because the nurse in question had, as she had said at the inquest, misinterpreted the drug sheet. The committee emphasised that it saw no causal connection between the complaints before it and the unfortunate death of the patient.

The most that could be said was that if the dose had been stated on the bottle, at the time the nurse was about to administer the morphine sulphate, she might have been able to make a secondary check by looking at that dosage.

What had come out was that the pharmacy had allowed an arrangement with the hospice to persist that did not match legal requirements. The Society alleged that the system complained of was inherently risk prone and illegal, involving the supply of prescription-only medicines, including Controlled Drugs, on the order of hospice staff and before prescriptions were received at the pharmacy authorising such supply. However, the system in place was not quite as extensively applied as that statement might seem to indicate, said the chairman. Over many years, Mr Jiwa, having had previously a telephone call, or latterly a faxed message, would take medicines to the hospice, hand them over and at the same time receive a prescription. In those circumstances, there was no illegality. He had the opportunity to check that what he had dispensed matched the prescription.

Where there was an “illegality” was where the order for the drugs came from the hospice to the pharmacy, where it was made up, and taken to the hospice not by Mr Jiwa but by a driver who was not a pharmacist. Although as little as 10 minutes may have elapsed from the time he handed the drugs to the hospice and returned to the pharmacy where the prescription would be checked against what had had been dispensed, nevertheless that arrangement included a stage that in law was not permitted.

In the committee’s view, it was going too far to say the system was inherently risk prone. However, an illegal arrangement had been in place on a number of days each week over a number of years. The system had been followed for the best of motives, but that was not sufficient to remove the taint of illegality.

The committee noted with approval that as soon as the system was revealed, immediate steps had been taken to remedy the situation. Accordingly, no further action would be taken against the superintendent pharmacist or the company.

The chairman pointed out that pharmacists should ensure that they did not operate in any way which was illegal, albeit only for brief intervals. The committee concluded therefore that Mr Jiwa had been guilty of misconduct. However, rather than striking him off the register, the committee proposed instead to reprimand him. The committee was satisfied hat he had acted from the best of motives; excellent references had been provided on his behalf, showing that over the years he had made a significant contribution to his community, and he had had a distinguished career as a pharmacist.