The Society

Statutory Committee

Reprimand for dispensing medicine with expiry date and batch number removed Dispensing foil-packed tablets from which the expiry date and batch number had been removed has led to an Oxford pharmacist being reprimanded by the Statutory Committee [more]

Reprimand follows cluster of dispensing errors A cluster of dispensing errors over a few days has resulted in a pharmacist being reprimanded by the Statutory Committee [more]

Reprimand for dispensing medicine with expiry date and batch number removed

Dispensing foil-packed tablets from which the expiry date and batch number had been removed has led to an Oxford pharmacist being reprimanded by the Statutory Committee.

At its meeting on 11 July 2001, the committee inquired into the case of Michael John Proctor, proprietor of Northway Pharmacy, 53 Westlands Drive, Headington, Oxford (his registered address) and also of Marston Pharmacy, 11 Old Marston Road, Oxford. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Proctor had supplied to a patient on prescription two foil strips of cerivastatin tablets with the batch number and expiry date removed and that those tablets may have been medicine returned from a patient. It was also alleged that there had been medicines returned by patients on the dispensary shelves at Northway Pharmacy.

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

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

The committee heard that on 18 August 2000, Mr Proctor, who was normally the pharmacist in charge at Northway Pharmacy, was working at Marston Pharmacy because the regular pharmacist there was on holiday. He dispensed a prescription for 28 cerivastatin 300mcg tablets, supplying the tablets in a white skillet. This was found to contain two foil blister strips of Lipobay 300 tablets; the ends of the strips had been cut off so that no batch number or expiry date was visible.

The patient complained to the Society. As a result, an inspector visited Mr Proctor at Northway Pharmacy to interview him about the matter. While there, the inspector found what appeared to be patient-returned medicines on the dispensary shelves. These were a bottle containing sotalol tablets, labelled for a named patient with a Marston Pharmacy address label, and another bottle labelled bendrofluazide 5mg tablets bearing a Northway Pharmacy label.

Mr Proctor had accepted responsibility for the error made in the dispensed medicine and for the presence of medication that should not be dispensed on the shelves at Northway Pharmacy.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said Mr Proctor had accepted that the cerivastatin dispensed might well have been returned medication but denied having removed the batch number or expiry date. While there was no direct evidence that he had personally trimmed the foil to remove the batch number and expiry date, it was difficult to imagine circumstances in which that might have been done other than as a deliberate attempt to remove that information.

The dispensing of prescribed drugs with the batch and expiry date removed amounted to serious professional misconduct. It would not suffice for a pharmacist, while regretting the incident, to say that he could not explain how that removal came about.

The chairman continued: "... it is the responsibility of any pharmacist dispensing to ensure that what is handed over has a batch number and expiry date displayed on it. The requirement for both should be very obvious and must be strictly observed." He said the committee would continue to take that view in similar cases that came before it.

The matter of returned medicines being on the dispensary shelves, although undesirable and not a practice of which the committee approved, was of less significance.

The committee had reprimanded Mr Proctor on a previous occasion, and in such circumstances removal from the register might have seemed inevitable; however, that case had been very different from the present one, the chairman noted. The procedures that Mr Proctor now had in place in his pharmacies represented a significant improvement, and impressive references had been presented on his behalf. The committee ordered Mr Proctor to be reprimanded.

Reprimand follows cluster of dispensing errors

A cluster of dispensing errors over a few days has resulted in a pharmacist being reprimanded by the Statutory Committee.

At its meeting on 19 July 2001, the committee inquired into the case of Godwin Akinwale Bajomo, whose registered address is 68 Landseer Road, Enfield, Middlesex. A complaint had been received from the Royal Pharmaceutical Society alleging that on 17, 19 and 23 May 2000 Mr Bajomo had made dispensing errors and that between 18 and 23 May 2000 he had attended for work despite feeling unwell.

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

Revantha Amarasinha, of counsel, instructed by Chase Christopher Roberts (solicitors) represented Mr Bajomo, who was present at the hearing.

The committee heard that on the relevant dates Mr Bajomo was acting as locum pharmacist at Pharmacy Direct, 202 Shirley Road, Southampton. On 17 May 2000 a pharmacy paper bag containing nitrazepam, fluoxetine and chlordiazepoxide was posted through a patient's letterbox. The label carried her name and address and indicated that the medicines had been dispensed at Pharmacy Direct. In fact, the medication had not been prescribed for her nor had she been expecting to receive any medication. She telephoned the pharmacy immediately and after discussing whether the medicines could be picked up by the pharmacy that same day, made arrangements to return them herself the following day. The patient complained to the local health authority.

It transpired that there had been confusion at the pharmacy over the patient who received the medication and a prescription for another patient with a similar name.

On 19 May 2000, a patient who had been prescribed 14 capsules of fluconazole 50mg was given instead one capsule of 150mg. When she returned to the pharmacy to query this she was given four 50mg capsules and asked to return for the remaining 10. When she returned again to collect the balance she was also given 20 Erymax 250mg capsules and 100 co-proxamol tablets that had not been prescribed for her.

The third error occurred on 23 May 2000, when Mr Bajomo dispensed 56 mefenamic acid 500mg tablets on a prescription calling for metformin 500mg tablets.

When Mr Bajomo was interviewed by one of the Society's inspectors on 6 June 2000, he admitted the errors and said he had felt unwell at the time.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said that Mr Bajomo had returned to the United Kingdom from Nigeria some weeks before the incidents and had initially believed he was suffering from malaria. In the event, it turned out to be 'flu and he made a relatively rapid recovery. The committee did not believe that his state was so serious that he should not have been at work but it should have been enough to make him be more assiduous to have his dispensing double checked.

The dispensing errors, however, did amount to such misconduct as to render him unfit to be on the register, said the chairman. However, Mr Bajomo had had a long and blameless career and had produced excellent references. The committee felt that it would be in his own best interests if, as he himself had suggested, he were to retire in the next 12 months.

Mr Bajomo was ordered to be reprimanded.