The Society

Statutory Committee

Pharmacist’s alcohol problems lead to striking-off order A pharmacist who had been unfit to carry out his professional duties because of drink problems has been ordered to be removed from the register by the Statutory Committee [more]

Reprimand for pharmacist whose “crass error” led to patient’s death The death of a patient following a “crass” dispensing error has led to a London pharmacist being reprimanded by the Statutory Committee [more]

Failure to apply dispensary stock check and control systems leads to reprimand A reprimand, conditional upon him not acting as the pharmacist in control of a pharmacy, has been administered to a Dorset pharmacist [more]

No further action after pharmacist’s driving conviction The Statutory Committee has concluded that no further action should be taken in the case of a pharmacist who had been convicted of driving while under the influence of alcohol [more]

Pharmacist’s alcohol problems lead to striking-off order

A pharmacist who had been unfit to carry out his professional duties because of drink problems has been ordered to be removed from the register by the Statutory Committee.

At its meeting on 13 March, the committee inquired into the case of Alistair Bell, of 54 Barbeth Way, Oakvale Park, Condorrat, Cumbernauld, Glasgow. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that, on various dates between 1 September 2000 and 20 October 2000, Mr Bell’s conduct while attending as a locum pharmacist at four pharmacies indicated that he had been in an unfit state to carry out his professional duties and that he might in consequence have been guilty of misconduct such as to render him unfit to have his name on the register.

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

Mr Bell was present at the inquiry and was represented by Ralph Shipway, of Le Brasseur J. Tickle (solicitors).

The committee heard that there had been a “pattern of behaviour” noticed by staff at pharmacies where Mr Bell had been employed during September and October 2000. On 1 September, at a pharmacy in Fife, he was said to have smelled of alcohol when he arrived and spent a significant amount of time on his mobile telephone while many prescriptions were waiting to be dispensed and members of the public were waiting for them.

At the same pharmacy, on 22 September, he was said to have arrived late, smelling of alcohol. Instead of checking 30 prescriptions that had been prepared, he left the pharmacy to use his mobile telephone. After lunch, his condition deteriorated and he indicated to a member of staff that he could not cope. He was said to have made errors and mislabelled prescriptions.

At a pharmacy in Glasgow on 23 September he had again arrived late, smelled of alcohol, spent significant time on the telephone and left the premises on three occasions for between 20 and 30 minutes.

A final allegation arose from a visit by one of the Society’s inspectors to Mr Bell when he was at a pharmacy in Dunfermline on 20 October 2000. The inspector said she had first met Mr Bell on 7 September on a routine visit to a pharmacy where he had been the locum. On that occasion, she had had no concerns about his conduct or appearance. Then, on 19 October, following reports about Mr Bell’s behaviour, she had interviewed him, with another inspector. He had become distressed and, because of her concern about him, she had decided to visit him the following day, going to the pharmacy shortly after 9.05am. Mr Bell had smelled of drink, his clothes had been dishevelled and he had had difficulty in concentrating. The inspector had formed the opinion that he was unfit for work, arranged for a relief pharmacist to attend the pharmacy and had driven Mr Bell home.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that what emerged was a troubling pattern of Mr Bell smelling of drink on arrival at the pharmacies at which he was a locum, being preoccupied and in a number of respects acting in a fashion falling below the standard to be expected of a pharmacist in a pharmacy. Staff at the pharmacies, and their employers, had been sufficiently concerned to complain to the Society.

The chairman pointed out that the committee was not a health committee, although in troubling cases such as the present one it might have been more appropriate for a health committee to have dealt with the matter than the Statutory Committee. It was noted that Mr Bell had a history of alcohol abuse and had twice had treatment at Birdsgrove House, from which he had relapsed. Unhappily, said the chairman, Mr Bell had not been responsive to the advice given to him and did not yet appear to appreciate what would be required of him if he was to continue as a pharmacist.

The facts of 0misconduct had been established and the committee ordered that Mr Bell’s name should be removed from the register. The chairman advised Mr Bell that the decision to remove his name was not one that would necessarily hold forever; but he could not solve his problems on his own. There were good sources of advice available to him and he would have to be motivated and prepared to take advantage of them.

Mr Bell had three months in which to appeal against the decision.

Reprimand for pharmacist whose “crass error” led to patient’s death

The death of a patient following a “crass” dispensing error has led to a London pharmacist being reprimanded by the Statutory Committee.

At its meeting on 13 February, the committee inquired into the case of Teresa Lawson, of 41 Stock Street, Plaistow, London E13. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that the supply by Ms Lawson of glibenclamide on a prescription for frusemide, and labelling the glibenclamide as frusemide, with a dosage different from that prescribed, might demonstrate misconduct that rendered Ms Lawson unfit to have her name on the register.

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

Rajiv Menon, of counsel, instructed by Bindman & Partners (solicitors), represented Ms Lawson, who was present at the inquiry.

The committee heard that on 1 December 1999, when Ms Lawson was working at a Boots The Chemists pharmacy at 68 High Street, Barking, a customer had brought in a prescription for his wife’s medication. While waiting to be attended to, the customer observed that the staff in the dispensary were in a group, laughing. Ms Lawson took the prescription, placed it by the computer, typed labels and selected two cartons from the carousel where the medicines were stored. She labelled the cartons and handed them to the customer.

The prescription she had dispensed had called for frusemide tablets at a dose of two tablets, twice daily; the cartons, however, although labelled frusemide, contained glibenclamide, stating the dose as two tablets daily. The customer gave his wife two tablets that day and a further five tablets on the following day. The patient collapsed and her doctor was called. He recognised that the wrong tablets had been supplied and the patient was admitted to hospital, where she died on 4 December.

At the inquest on 1 June 2000, a verdict of accidental death was recorded.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC), said that Ms Lawson remembered little or nothing about the day in question, and the committee had been given no real explanation for the errors. While it was understandable that the error over the dosage could have happened because Ms Lawson had hit the wrong key on the computer, the major error, of dispensing the wrong medication, was more difficult to understand. The medicine prescribed and named on the labels was obviously not the same as that named in large print on the two cartons. Even with the label stuck on the carton, it was quite clear what they contained. It could only be a matter of speculation why such an obvious error had occurred.

The fact that staff in the dispensary had been giggling and laughing might have been such a distraction that Ms Lawson failed to follow through the checks that she would otherwise have made, said the chairman.

The committee emphasised that the dispensing error in this case was not in the same category as one in which, possibly, a relatively inexperienced pharmacist had read the quantities erroneously, misunderstood the strength of a mixture, or where similar names had led to a mistake.The present case was a crass error with tragic consequences, leading to the contemplation of serious criminal proceedings, and a coroner’s inquest.

In the circumstances, the committee would be bound to conclude that this was not only an error amounting to misconduct, but misconduct of such a nature as to render Ms Lawson unfit to be on the register. However, since those events, said the chairman, Ms Lawson had successfully undergone a period of rigorous retraining, including completing a project on dispensing errors; her employers continued to express confidence in her. As a young pharmacist in the early years of her professional career, Ms Lawson had learned a lesson that would remain with her for the rest of her life.

The committee ordered that Ms Lawson should be reprimanded, with the rider that she should not be employed as a sole pharmacist for 12 months.

The chairman added that it was felt desirable that, wherever possible, the two-stage procedure of initialling both the “dispensed by” and “checked by” boxes on dispensed medicines should be followed.

Failure to apply dispensary stock check and control systems leads to reprimand

A reprimand, conditional upon him not acting as the pharmacist in control of a pharmacy, has been administered to a Dorset pharmacist.

At its hearing on 15 March, the committee inquired into the case of Anilkumar Ishverbhai Patel, of 118 Dunyeats Road, Broadstone, Dorset. The committee had received a complaint from the Council of the Royal Pharmaceutical Society alleging that Mr Patel’s failure to maintain systems for the proper control and checking of pharmacy stock at his pharmacy at 960 Wimborne Road, Moordown, Bournemouth, might demonstrate such misconduct as to render him unfit to have his name on the register.

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

David Aaronberg, of counsel, instructed by Charles Russell (solicitors), represented Mr Patel, who was present at the inquiry.

The committee heard that, following a complaint from a patient that outdated Provera tablets had been supplied to her, one of the Society’s inspectors had visited Mr Patel’s pharmacy with a colleague on 14 June 2000. When they came to examine the stock of Provera tablets, Mr Patel had produced a parallel import pack marked with an expiry date of January 2002. Inside that pack was a cut blister strip containing six tablets with the batch and expiry date indicated on the carton, also a smaller carton labelled UK Provera 5mg tablets and an expiry date of 08/98. Inside that smaller carton was a strip of 10 tablets bearing an expiry date of 08/98, and a cut strip of five tablets with the expiry date 03/98.

Further, in a carton labelled 28 Lagap co-amilofruse tablets, batch 6910J, expiry date 02/2002, no tablets of that batch were found but there were six strips of tablets from three different manufacturers, some of which were cut strips, with no expiry date and one with no batch number. There was also a large number of blister strips and cut blister strips loose on the shelves, inadequately labelled.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC), said that the inspection had clearly indicated that the system Mr Patel had believed to be in place for controlling and checking dispensary stock was not operating satisfactorily. That was particularly disappointing because the Society’s inspector had previously, at the request of the committee, taken pains to assist Mr Patel to establish satisfactory systems and to that end had made a number of visits to the pharmacy over the years.

In April 2000, when the inspector had visited the pharmacy, there had been no shortcomings such as had been described. It was obviously a matter of great disappointment that shortly after that visit the system had deteriorated.

The committee concluded that there was a failure to maintain systems for proper control. That was conduct such as to render Mr Patel unfit to be on the register. If Mr Patel had retained the pharmacy and had wished to continue with himself in control, they would have ordered the removal of his name from the register. However, he had sold the pharmacy. He had since since worked only part-time, and had stood in for his pharmacist wife at another pharmacy they owned in partnership, and of which she was in charge, on occasions when she had been off.

In the circumstances, and on condition that he should not in future seek to buy another pharmacy and be the pharmacist in control of it, the committee had decided that Mr Patel should be reprimanded.

No further action after pharmacist’s driving conviction

The Statutory Committee has concluded that no further action should be taken in the case of a pharmacist who had been convicted of driving while under the influence of alcohol.

At its meeting on 15 March, the committee inquired into the case of Pamela Catherine Tucker, of 32 Moorfield Drive, Parkgate, Wirral. Information had been received that on 7 October 1999, at Wirral magistrates’ court, Mrs Tucker had pleaded guilty to and been convicted of driving a car when the amount of alcohol in her breath was in excess of the prescribed limit.

Mrs Tucker had been fined £350, with £45 costs, had had her licence endorsed and had been disqualified from driving for two years.

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

Andrew Ford, of counsel, instructed by Thompsons (solicitors), represented Mrs Tucker, who was present at the inquiry.

The committee heard that on 9 September 1999 the police had been called to an accident involving two vehicles, one of which was Mrs Tucker’s. The officer noticed her breath smelled of intoxicants and a breath test was positive. When she was given a breath test at at the police station, she gave a reading of 78µg in 100ml.

The committee heard that, on the day of the accident, Mrs Tucker, whose mother had recently died, had gone to her late mother’s empty house to receive the results of the post mortem which had been sent there. This had distressed her, and she had drunk some cider. On her way home, her car had clipped a light protruding from a wagon, and the police had been called.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC), said that Mrs Tucker had been drinking on a day when she had received distressing information and was further distressed by the fact that she was in her mother’s house. Importantly, on the day in question she had not been on duty as a pharmacist, and there was no evidence whatsoever that there was any underlying problem with alcohol.

The committee concluded that the conviction did not reveal conduct of such a character as to render her unfit to be on the register, and that no further action should be taken.