The Society

Statutory Committee

Lack of professional indemnity cover leads to striking-off order The Statutory Committee has ordered the removal from the register of a Northumberland pharmacist who had practised without professional indemnity cover over a period of years, had failed to keep proper records of Controlled Drugs and had neglected the routine administration of paperwork [more]

Dispensing errors result in reprimand for pharmacist A Kent pharmacist who had made a number of dispensing errors has been ordered to be reprimanded by the Statutory Committee [more]

Reprimand for pharmacist in "peppermint water" case A pharmacist who was supervising a preregistration trainee when a dispensing error with tragic consequences was made has been reprimanded by the Statutory Committee [more]

Lack of professional indemnity cover leads to striking-off order

The Statutory Committee has ordered the removal from the register of a Northumberland pharmacist who had practised without professional indemnity cover over a period of years, had failed to keep proper records of Controlled Drugs and had neglected the routine administration of paperwork.

At its meeting on 22 May 2001, the committee inquired into the case of John Dickinson, of Dickinson Pharmacy, Unit 9, Spar Business Centre, Cramlington, Northumberland. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging: (1) that Mr Dickinson had failed to ensure that professional indemnity insurance arrangements were in place between 1 June 1955 and 8 May 2000; (2) that Mr Dickinson had failed to maintain the pharmacy's Controlled Drugs registers in accordance with the requirements of the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations 1985; and (3) that Mr Dickinson had failed to have in place arrangements for the routine administration of post and paperwork.

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

Mr Dickinson was present at both hearings and represented himself.

The committee heard that on 12 April 2000, one of the Society's inspectors had paid a routine visit to Mr Dickinson's pharmacy and found the Controlled Drugs register deficient in the following respects: loose sheets of unnumbered pages had been used for the morphine section; there were crossings out in the same section, and no dosage forms had been stated in entries in the morphine section. In addition, no entries had been made in the separate methadone book although supplies had been made to addicts between 6 April and 12 April 2000. A quantity of papers, unopened mail and books had been found on the dispensary side bench, and in an upstairs stock room where the Controlled Drugs cabinet was sited there were boxes of unopened mail, including copies of The Pharmaceutical Journal and of the January 2000 edition of 'Medicines, ethics and practice: a guide for pharmacists'. Mr Dickinson had been unaware of recent drug safety information published, including drug alerts and drug safety information.

The inspector advised Mr Dickinson, who had seemed distressed at the time, to obtain new sections for his Controlled Drugs register from the National Pharmaceutical Association and suggested that he might like to contact someone at the Listening Friends Scheme. She then left the pharmacy, indicating she would return in two weeks.

On the second visit, on 27 April 2000, the inspector was accompanied by a police officer. The Controlled Drugs register was examined; no new pages had been inserted. It was established that no entries had been made for 31 instances of purchases of Controlled Drugs, and details of 45 instances of supply had not been entered. When asked whether he had professional indemnity insurance, Mr Dickinson at first told the inspector that he had, but later admitted that it had lapsed some time previously.

Mr Dickinson had subsequently been charged with three offences of failing to keep proper records and had received a conditional discharge and ordered to pay £118 costs.

Financial and personal problems

Addressing the committee, Mr Dickinson said that starting in 1995 he had had financial and personal problems that had led to a lapse in the organisation of his business and he had neglected to renew his NPA membership, which included his indemnity insurance premiums. With help from the Society's inspector and the police chemist inspections officer, that situation had now been corrected and the problems sorted out.

The committee adjourned the hearing to consider its decision.

At the resumed meeting on 19 June, the chairman (Lord Fraser of Carmyllie, QC) said that Mr Dickinson had not challenged any of the facts. Knowing that Controlled Drug registers were quickly available from the NPA, the inspector had asked Mr Dickinson if he was a member. He explained that his membership had lapsed but showed the inspector a cheque stub, purportedly for a payment to the NPA for renewed membership and the Controlled Drug register sections he required. In fact, the cheque he had sent was not honoured. When asked about professional indemnity insurance, he claimed he had a policy with the Bank of Scotland. He later admitted that no such policy existed and his indemnity cover had lapsed on 1 June 1995. He had then been carrying on business as a pharmacist dispensing to the public for almost five years without professional indemnity cover, notwithstanding what was expressly required in Standard 6 (1) of the Code of Ethics.

Between 17 February 2000 and 27 April 2000 there had been 31 instances of failing to enter purchases of Controlled Drugs and, between 27 January 1998 and 11 April 2000, 45 instances of failure to enter supplies of Controlled Drugs. Loose sheets had been used for recording the purchase and supply of morphine, pethidine and methadone over two or three years.

Mr Dickinson had said that he had had financial problems and had "buried his head in the sand", neglecting to open his mail for fear of what it might contain. He had also had personal problems, which the committee accepted.

It had been confirmed that the problems had largely been resolved and his pharmacy had been in good working order during the inspector's recent visits. However, said the chairman, the emotional upset in early 2000 did not explain a failure to carry professional indemnity cover for nearly five years. Mr Dickinson had lied to the inspector over this and it had to be concluded that he had done so appreciating the seriousness of his failure to maintain proper cover.

The committee considered this failure alone would amount to such misconduct as to render him unfit to be on the register. Coupled with the other deficiencies he had admitted, there was no doubt about that.

The committee ordered that Mr Dickinson's name should be struck from the register. He had three months to appeal against the decision.

Dispensing errors result in reprimand for pharmacist

A Kent pharmacist who had made a number of dispensing errors has been ordered to be reprimanded by the Statutory Committee

At its meetings on 14 June 2000 and 20 June 2001, the committee inquired into the case of Bharatkumar Ramanbhai Patel, of Newington Pharmacy, 47 Newington Street, Ramsgate, Kent. Mr Patel was the proprietor of two pharmacies, one at Newington Pharmacy, 47 Newington Road, Ramsgate, Kent, and the other at 326 Margate Road, Ramsgate. A complaint had been received from the Council of the Royal Pharmaceutical Society that four dispensing errors had been made while Mr Patel was in charge of the Newington pharmacy. It was alleged that those errors, and Mr Patel's failure to ensure safe and accurate dispensing and checking practices, might demonstrate that he had been guilty of such misconduct as to render him unfit to be on the register.

To put the facts of the case before the committee, Geoff Hudson (Penningtons, solicitors) was present at the first hearing. David Bradly, of counsel, instructed by Penningtons, atttended the second hearing.

Mr Patel was present at both hearings, represented by David Reissner (Charles Russell, solicitors).

The committee heard that the Newington Pharmacy, where Mr Patel spent most of his time, had a busy dispensing practice. The complaints about the alleged dispensing errors had all emanated from a medical practice close to the pharmacy. The first concerned the supply on 26 May 1999 to a diabetic patient of a bottle labelled methyldopa 500mg tablets when metformin 500mg had been ordered.

A second error was made on 6 August 1999 when, on a prescription calling for a number of items including dothiepin capsules 25mg and tamoxifen tablets 20mg, no dothiepin capsules had been dispensed but a 30-tablet tamoxifen 20mg box was labelled as dothiepin 25mg "take one at night".

In a third instance, on 5 October 1999, a patient receiving indapamide had had her dose increased from 1.5mg tablets to 2.5mg tablets but a prescription for the higher strength was filled with 1.5mg tablets. The error was noticed when the patient's doctor examined her to review the effect of the new strength on her blood pressure.

On the fourth occasion, on 4 November 1999, a prescription calling for Combivent 2.5ml unit dose vials was dispensed with a mixture of Combivent and Atrovent vials in a skillet labelled "Combivent unit dose vial 2.5ml as directed".

A number of references, including letters from three of the four patients whose prescriptions had been involved in the alleged errors, were presented on Mr Patel's behalf.

The committee chairman (Lord Fraser of Carmyllie, QC) said that, of the four complaints, the first, alleging the supply of methyldopa instead of metformin was not supported by evidence. The pharmacy did not normally stock methyldopa, and none of the tablets allegedly dispensed had been produced in evidence, having been consumed by the patient. The committee would deal with it as having been the right drug, but mislabelled when it was handed over to the patient.

The facts of the remaining three cases had not been disputed; the error with the Combivent vials had been discovered before any had been used.

The chairman emphasised that it was a primary responsibility of any pharmacist to ensure that the drugs he or she dispensed were made up according to the prescription from the medical practitioner. That was one of the primary duties the pharmacist owed to the public and society as a whole. He continued: "In a sense, it matters not whether there were no disastrous or fatal consequences flowing from that, as there are not different types of prescription which enable the individual pharmacist to be more or less reckless, depending on the type of drug to be dispensed."

On that basis, the committee concluded that Mr Patel's conduct fell just on the side of rendering him unfit to be on the register.

Before retiring to make its decision on the action to be taken, the committee was advised that Mr Patel had twice previously been reprimanded for dispensing errors.

The chairman said the committee had decided to postpone its decision for 12 months. At the end of that period they would want assurance that Mr Patel had sold his second pharmacy, as he had indicated he wished to do, to relieve the pressure of work on him, and had not acquired another. The committee would want clear and unequivocal evidence that the dispensing protocol in the pharmacy was rigorously adhered to. They would also want to see indication of an improved relationship with the nearby medical practice.

At the resumed inquiry on 20 June 2001, the committee heard evidence that the conditions laid down at the earlier meeting had been complied with.

The chairman announced that it had been decided that Mr Patel would be reprimanded.

Reprimand for pharmacist in "peppermint water" case

A pharmacist who was supervising a preregistration trainee when a dispensing error with tragic consequences was made has been reprimanded by the Statutory Committee.

The committee made its decision on 19 June 2001 in an inquiry that had been adjourned from 11 December 2000 and concerned Lisa Jane Taylor-Lloyd, of 91 Kestrel Drive, Coppenhall, Crewe, Cheshire. At the first meeting, the committee heard that information had been received that at Chester crown court on 1 March 2000 Miss Taylor-Lloyd had pleaded guilty to and been convicted of supplying a medicinal product not of the nature and quality specified in the prescription, contrary to section 64 of the Medicines Act 1968; she had been fined £1,000.

Geoff Hudson, of Penningtons (solicitors), appeared in order to place the facts of the case before the committee at the 11 December 2000 hearing.

Miss Taylor-Lloyd was present at the 11 December 2000 hearing, when she was represented by Neil Flewitt, of counsel, instructed by Berrymans Lace Mawer (solicitors).

The committee heard that on 29 April 1998 a prescription for "Alder Hey peppermint water", intended for a five-day-old baby boy, had been presented at a Boots The Chemists pharmacy in Hallwood Health Centre, Runcorn, Cheshire. The prescription had been handed to Miss Taylor-Lloyd. She had noted the child's age on the prescription and passed it to a preregistration trainee for dispensing, believing it would be good experience for him. The amount prescribed, 150ml, required 3.75ml of peppermint emulsion and 75ml of chloroform water, double strength. The latter had to be prepared by diluting 3.75ml of concentrated choroform water to 75ml.

Miss Taylor-Lloyd saw the trainee measure out the peppermint emulsion correctly. However, it appeared that, not realising that there was a difference between concentrated chloroform water and the double-strength preparation, he measured out 75ml of the concentrate and used that in making up the dispensed preparation. Miss Taylor-Lloyd did not see that, nor did she check the trainee's work.

She handed out the mixture to the infant's mother, with a dropper for administration. When, later that day, the father started to give the baby the prescribed dose, it stopped breathing and suffered a cardiac arrest. The child suffered severe brain damage and died on 17 May, two-and-a-half weeks after the incident.

A prosecution of Miss Taylor-Lloyd and the preregistration trainee had followed; an initial charge of manslaughter had been dropped and the Medicines Act offence substituted. At the trial, prosecuting counsel had said that the formula, as written in the pharmacy's book of formulae, was confusing and was out of date in that it referred to chloroform water, double strength. It had also been noted that, because Miss Taylor-Lloyd had qualified only 21 months previously, she was not qualified to act as a preregistration tutor, nor was the Hallwood pharmacy recognised for taking preregistration trainees. The prosecution had also referred to the "undesirable difference" at the material time in practice between hospital and community pharmacies as to the validity of formulae and the use of worksheets in extemporaneous preparations.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC), noted that the "division in practice" that there was said to have been between hospital and community pharmacies no longer existed. "[see advice in The Pharmaceutical Journal, 30 May 1998, (p783)] If it had persisted, he said, the committee "would have had some very hard things to say about that".

The facts of the case were not disputed; behind them lay a very real and very public tragedy. Miss Taylor-Lloyd had been through a very stressful period in her life

The committee decided that the case should be adjourned for six months. The chairman said that if nothing adverse concerning Miss Taylor-Lloyd was heard then, she could expect a reprimand. During that time it was hoped that Miss Taylor-Lloyd would recover her self-confidence and allow her to apply her own high standards. The chairman said that Boots had behaved in an exemplary fashion in doing all it could to ensure that what training she might require was provided; and it had taken steps to ensure that tragic errors of this character should not be repeated in the future.

At the resumed inquiry on 19 June 2001, the case concluded with an order by the committee that Miss Taylor-Lloyd should be reprimanded.