The Society

Statutory Committee

Failure to observe conditions after dispensing errors leads to striking off A pharmacist who had made a number of dispensing errors and had neglected to comply with conditions placed on his subsequent professional activities has been removed from the register by the Statutory Committee [more]

Pharmacist reprimanded for dispensing and CD errors The Statutory Committee has ordered that a pharmacist who committed a number of dispensing errors and passed on the key of a Controlled Drugs cabinet to an unauthorised person should be reprimanded [more]

Reprimand follows convictions for CD offences Two London pharmacists have appeared before the Statutory Committee following convictions arising from failure to comply with the regulations concerning entries in Controlled Drugs registers [more]

Failure to observe conditions after dispensing errors leads to striking off

A pharmacist who had made a number of dispensing errors and had neglected to comply with conditions placed on his subsequent professional activities has been removed from the register by the Statutory Committee.

At its meetings on 13 July 2000, 16 July 2001 and 9 October 2001, the committee inquired into the case of Miroslaw Jaworowski, of 23 Locklands Lane, Irlam, Manchester. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that while pharmacist in charge of K's Chemist, 5 Ordsall District Precinct, Salford, Mr Jaworowski had committed a number of dispensing errors and had made incorrect entries in the Controlled Drugs register.

Geoff Hudson, of Pennington's (solicitors) appeared in order to present the facts of the case to the committee at each hearing.

Mr Jaworowski attended each hearing and represented himself.

The committee heard that the first error complained about alleged that a tube of aciclovir cream had been dispensed on 9 November 1998 when the prescription called for aciclovir 200mg tablets. The second error occurred on 14 December 1998 when a vial of Depo-Provera was dispensed on a prescription ordering Depo-Medrone with Lidocaine. A labelling error was made on 26 October when the container of a prescription for carbamazepine 100mg tablets was labelled carbamazepine 200mg.

Then, on 11 December 1998, a monitored dosage tray which was labelled as containing dothiepin 75mg, nitrazepam 5mg, frusemide 40mg and amlopidine 5mg, as prescribed, was found to contain the dothiepin and nitrazepam but not the amlopidine or the frusemide; the tray also contained a tablet believed to be bendrofluazide, which had not been prescribed.

Finally, entries in the Controlled Drugs register for supplies of diamorphine injections dispensed on prescriptions dated 1 and 2 October 1998 did not correspond with the prescriptions. It appeared that diamorphine 100 mg ampoules had been ordered for a terminally ill patient but that strength was not obtainable at the time. After discussion with the prescriber, Mr Jaworowski had supplied ampoules of a lesser strength; some confusion had resulted and the entries in the register did not match up with what had been supplied.

Giving the committee's conclusion at the first hearing, the chairman (Lord Fraser of Carmyllie, QC) said that the five allegations made by the Society had been established. It was vitally important that the Controlled Drugs register should accurately reflect what had been delivered from the pharmacy.

The committee felt Mr Jaworowski, at the time the incidents took place, had been working under exceptionally trying circumstances at the pharmacy. They were satisfied that he had been in a difficult position. However, he had since changed his job to work at another pharmacy with a smaller amount of dispensing. A letter from his present employers expressed satisfaction with the way he performed his professional duties and indicated that they hoped Mr Jaworowski would continue to work for them.

In those circumstances the committee had decided to postpone a decision on the following conditions. His present employers should undertake to inform the Society in the event of Mr Jaworowski leaving their employ, as a significant factor in their decision was the changed circumstances in which he was now working. They also would require an undertaking from Mr Jaworowski that if anything untoward should happen in his performance of his professional duties, he should communicate with the Society.

At the resumed hearing on 16 July 2001, the committee heard that Mr Jaworowski's employment had ended on 11 December 2000, the reason given being that, contrary to an agreement, he had not informed his employer that he had made some dispensing errors. Mr Jaworowski had informed the Society that since leaving that employment he had not been employed in a pharmaceutical capacity. He said he now had an offer of a part-time post.

The committee decided to postpone its decision for a further three months on condition that Mr Jaworowski provided a written undertaking that he would not practise as a pharmacist during that time. A second condition was that he should arrange that any prospective employer should write to the Society setting out their agreement to employ him and indicating the type of work, hours of employment and other details.

At the resumed hearing on 9 October 2001, the chairman, giving the committee's decision, said that the committee had received no written undertaking from Mr Jaworowski about not taking up pharmaceutical employment. And it had had no indication whatever from any prospective employers whether they would be prepared to offer Mr Jaworowski a post or whether a job remained open for him.

Those two failures to provide responses reasonably asked for and based on Mr Jaworowski's own indications of his employment prospects were serious matters. It was clearly time to draw the inquiry to a close, said the chairman. The committee ordered that the name of Mr Jaworowski should be removed from the register.

He had three months in which to appeal.

Pharmacist reprimanded for dispensing and CD errors

The Statutory Committee has ordered that a pharmacist who committed a number of dispensing errors and passed on the key of a Controlled Drugs cabinet to an unauthorised person should be reprimanded.

At its meetings on 11 September and 10 and 11 October 2001, the committee inquired into the case of Karam Al-Nimri, of 2 Old Brompton Road, Suite 403, London SW7. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that, on 11 June 2000 while acting as a locum pharmacist in charge at a pharmacy in Margate and on 7 September 2000 at a pharmacy in Ramsgate, Mr Al-Nimri had made errors in dispensing. It was further alleged that on 10 June 2000 at a pharmacy in Tunbridge Wells he had incorrectly dated entries in the Controlled Drug register and had handed the key of the Controlled Drugs cabinet to an unauthorised person and instructed her to close the pharmacy at the end of the day.

David Bradly, of counsel, instructed by Penningtons (solicitors) was present at the hearings on 11 September and 11 October, and Geoff Hudson of Penningtons (solicitors) appeared on 10 October, in order to present the facts of the case to the committee.

Mr Al-Nimri attended each hearing, and represented himself.

At the hearing on 11 September 2001, Mr Al-Nimri asked for a postponement. He said he had been away from the UK until 2 September. He had e-mailed the Society on 30 July seeking postponement so that, he said, he could appoint counsel. That request, formally made on 13 August, had not been granted.

The chairman (Lord Fraser of Carmyllie, QC) pointed out that a number of witnesses had given their time to be present at the hearing that day. He said it was extremely unsatisfactory that a pharmacist should appear before the committee and fail to grasp the seriousness of the situation, and the importance of an appropriate degree of co-operation with the Society. He postponed the proceedings until 10 October.

At the resumed hearing, the committee heard that while Mr Al-Nimri was pharmacist in charge at the pharmacy at 47 Newington Road, Ramsgate, on the balance owing on a prescription for flucloxacillin capsules, an assistant had in error dispensed 14 fluoxetine 20mg capsules and left them for Mr Al-Nimri to check and initial. The error had not been identified and the medicine was handed out.

The second allegation concerned the mislabelling of a container of Carace 10 Plus tablets as lisinopril 10mg tablets, which was dispensed while Mr Al-Nimri was pharmacist in charge at a pharmacy at 326 Margate Road, Margate.

The remaining allegations concerned incidents while Mr Al-Nimri was locum pharmacist at the premises of Safeway, Tunbridge Wells. The first was that he had supplied 49 MST 30mg tablets on 10 June 2000 on a prescription calling for 28 to be supplied that day and a further 21 on 14 June; the second error alleged was that Mr Al-Nimri had supplied 56 MST 30mg tablets when the prescription had ordered 32 MST 30mg tablets.

A further two allegations of dispensing errors at the same pharmacy were not proceeded with as the material witness, who had been present at the first day's hearing (which had been postponed), had since emigrated. The final allegations were that two entries in the Controlled Drugs register on 10 June 2000 had been dated 10/10/00, and that Mr Al-Nimri had given the key of the Controlled Drugs cabinet to an assistant and told her to close the pharmacy at the end of the day.

Errors

Giving the committee's decision, the chairman said that the first error was of inadequate checking by Mr Al-Nimri; the second error, in labelling, would not, of itself, have been a particularly serious matter. The error by which the wrong date had been entered in the Controlled Drugs register was an obvious one that would have been made clear from the previous and succeeding entries.

With regard to the complaints relating to 10 June, when Mr Al-Nimri handed over the key of the Controlled Drugs cabinet to an unauthorised person, he should have known that it was for him not only to hold the key but to lock the cupboard and close the pharmacy before departing. Then there were on the same day the two dispensing errors relating to MST 30mg tablets. Mr Al-Nimri, said the chairman, had tried to persuade the committee that on the day in question he had suddenly become ill with diarrhoea. The committee was not wholly convinced by his account but would give him the benefit of the doubt.

The committee found the complaints had been established and that there had been misconduct such as to render Mr Al-Nimri unfit to be on the register. However, it had been decided to reprimand him. The chairman added that if Mr Al-Nimri were to appear before the committee again, he could not anticipate that it would deal with the matter with the same degree of leniency.

Reprimand follows convictions for CD offences

Two London pharmacists have appeared before the Statutory Committee following convictions arising from failure to comply with the regulations concerning entries in Controlled Drugs registers. No action was taken in respect of one pharmacist; his colleague, who had also been convicted for a CD storage offence, was reprimanded.

At its meeting on 23 November 2001, the committee inquired separately into the cases of Mahesh Patel, of 20 Endsleigh Mansions, Leigham Avenue, London SW16 and Amrik S. Gahir, of 91 Drewstead Road, London SW16.

The committee heard that at Camberwell Green magistrates' court on 16 October 2000 Mr Patel had pleaded guilty to and been convicted of making an incorrect entry in the Controlled Drugs register at Nine 2 Nine Pharmacy, 6–7 High Parade, Streatham, London SW16, in respect of Palladone, and of failing to make entries of the supply of Oramorph on two occasions. Mr Patel, a director of the company owning the pharmacy, Pharmacy Development Group Ltd, was pharmacist in charge at the material time. He had been fined a total of £1,000 and ordered to pay £50 costs.

On the same day and at the same magistrates' court, Mr Gahir, who was superintendent pharmacist of Pharmacy Development Group Ltd at the time, had pleaded guilty to seven offences under the Misuse of Drugs Act, all of which had taken place at the Nine 2 Nine Pharmacy. One offence was that a quantity of temazepam tablets had not been kept in a locked Controlled Drugs cabinet; six offences related to failure to date prescriptions for Controlled Drugs at the time of supply. Mr Gahir had been fined a total of £1,000 and ordered to pay costs of £50.

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

Mr Patel and Mr Gahir both attended their hearings and represented themselves.

At Mr Patel's hearing, the committee was told that that on 24 November 1999 a police Controlled Drugs officer on a routine visit to the pharmacy had found that entries dated 12 August 1999 had been made in the morphine section of the Controlled Drugs register in respect of the receipt and supply of Palladone capsules when the hydromorphone section should have been used. The officer had also found that, while entries for 50 Oramorph ampoules, 100mg in 5ml, obtained on 4 November 1999 had been correctly made in the register's section for morphine receipts, there were no corresponding entries for the supply on prescriptions on 4 and 18 November of 30 and 25 Oramorph ampoules, respectively.

When interviewed, Mr Patel had said in explanation that he had been too busy to make the entries on 4 November. That prescription, and the one dispensed on 18 November had, he said, ordered respectively 30 ampoules and 25 ampoules of Oramorph, 20mg in 1ml, a formulation not available. He had kept the prescriptions so that the prescriber could alter them. He had accepted that he should have made the appropriate entries that same day as the prescriptions were dispensed, or the day following.

The prosecution had followed.

At Mr Gahir's hearing, the committee heard that his offences had come to light during the same visit by the police officer to the pharmacy on 24 November 1999. The officer had noticed two containers of temazepam 10mg tablets and two of temazepam 20mg tablets on a shelf in the dispensary. He had also found six prescriptions for Controlled Drugs, relating to daily doses for addicts (one for diamorphine, the others for methadone), which had been dispensed on the previous day but had not been endorsed with the date at the time of supply.

The chairman (Lord Fraser of Carmyllie, QC) said that although the committee had heard the cases separately a single judgement would be delivered. Of Mr Patel, he said that the convictions had been admitted. Mr Patel had given evidence in a clear and forthright fashion. He had never been previously subject to any disciplinary proceedings before the Statutory Committee, nor had he been cautioned by the police. It was decided to take no further action in his case.

Turning to Mr Gahir, the chairman said that while the committee readily understood the difficulties that pharmacists faced with addicts coming into their premises, there had been no fewer than six failures on his part to date Controlled Drugs prescriptions at the time of supply. He had been open with the committee about his failure to keep temazepam in a locked Controlled Drugs cabinet, and they regarded that failure as serious.

Mr Gahir had previously received a police caution, in 1998, about the way in which he had been making entries in a Controlled Drugs register; further, he was at the time of the offences the superintendent pharmacist of the company. In the circumstances, the committee took a sterner view of his failure than that of Mr Patel.

Mr Gahir was then ordered to be reprimanded.

The chairman added a suggestion that the Society should make clear to pharmacists which section of the Controlled Drugs register should be used to enter Palladone.