The Pharmaceutical Journal
Vol 271 No 7267 p386-388
20 September 2003

Society summary

Reprimand for pharmacist who dispensed a prescribed overdose without checking more

Fraudulent prescription claims lead to striking off more

Reprimand for pharmacist who supplied patient with date-expired tablets after removing expiry date more

Striking-off after failings arising from alcohol problem more

Drink-related incidents lead to pharmacist’s striking-off more

Reprimand for pharmacist who dispensed a prescribed overdose without checking

A pharmacist who knowingly dispensed an overdose without checking with the doctor who prescribed it has been reprimanded by the Statutory Committee. The Chairman (Lord Fraser of Carmyllie, QC) said the case highlighted a "lack of symmetry" between the duties of a dispensing pharmacist and those of a prescriber. His reasoned decision is set out below.

At its meeting on 24 July 2002, the committee inquired into the case of Elaine Hutton, of 37 Badgers Wood, Park Lane, Cottingham, North Humberside. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that on 28 August 2001, as pharmacist on duty at a pharmacy at 42–44 King Street, Cottingham. It was alleged that Ms Hutton had supplied on a prescription five packs of 28 bisoprolol 10mg tablets labelled with the dose "take EIGHT daily" without contacting the prescriber when she knew, or should have known, that dose to be outside the normal prescribing limits. It was further alleged that the supply on the following day of three packs of 28 bisoprolol 10mg tablets, also labelled "take EIGHT daily", knowing that the patient had been hospitalised the previous day after taking one dose of eight 10mg tablets, might demonstrate misconduct such as to render Ms Hutton unfit to have her name on the register.

David Bradly, of counsel, instructed by Penningtons (solicitors) was present in order to place the facts of the case before the committee.

Ms Hutton was present at the hearing, and was represented by Jon Merrills, of counsel, instructed by French & Co (solicitors).

No advice

The committee heard that when the patient's wife had presented a prescription calling for 224 bisoprolol 10mg tablets, eight to be taken daily, five boxes of 28 were dispensed and handed out to her without advice or instructions other than to return for the remainder. Ms Hutton had not contacted the prescriber.

The patient took eight tablets, the dose on the label. He became ill and was admitted to hospital later the same day.

Next day, the hospital pharmacist telephoned Ms Hutton, explaining that the patient had become ill after taking a large dose of bisoprolol. Ms Hutton had responded by saying she assumed the prescription had initially been written by a hospital consultant before being rewritten by the patient's general practitioner. She had said she knew "strange doses" were used in hospital, adding that the doctors in Cottingham were "not interested" in her interfering in prescribing.

Ms Hutton told her dispensing assistant that the dose had been wrong and the hospital had asked why she had not queried it. She said she wished she had queried the dose, but "her hands were tied".

Dangerous overdose

Later the same day the patient's wife returned to the pharmacy with the owing slip for the balance of the bisoprolol tablets, Ms Hutton had told her that the drugs dispensed "could have been a dangerous overdose in certain circumstances". She handed over the remainder of the tablets, labelled, as before, "take EIGHT daily". When the patient's wife had asked her "Do you realise what you are giving me, this is three months' supply of an overdosed drug?" Ms Hutton had shrugged her shoulders and told her they would be needed.

During an interview by one of the Society's inspectors on 13 September 2001 Ms Hutton had accepted that the dose of 80mg bisoprolol daily was high and that she had never known a general practitioner or hospital doctor prescribe that dose. She said the medicine had been labelled "take EIGHT daily" because that was what the prescription had said. It had never occurred to her that there had been an error in transcription. The prescription had been computer generated and was legally correct. There were no indications on the prescription that an error had taken place. Ms Hutton told the inspector that she did not think that, knowing the patient had been readmitted to hospital, it had been professionally unacceptable to make a further supply.

However, the committee had decided that Ms Hutton should be reprimanded.

The chairman added that the reasons for the decision would be given at a later date, after an adjournment.

Reasoned decision

The case was resumed on 12 December. Lord Fraser said that the delay in giving his reasoned decision arose from his concern that there was a "lack of symmetry" between the duties of the dispenser and those of the prescriber.

The Code of Ethics stated, under the heading "Personal Responsibilities", that: "A pharmacist's concern, irrespective of their sphere of work, must be for the well-being and safety of the patients and public." That was further explained under "Supply of Prescribed Medicines": "(b) Every prescription must be professionally assessed by the pharmacist to determine its suitability for the patient. Pharmacists must ensure that the patient receives sufficient information and advice to enable the safe and effective use of the medicine."

The chairman continued: "it has repeatedly been regarded as commonplace that in the event of an unusually large or apparently erroneous or unclear prescription it is incumbent on the pharmacist to query that prescription with the prescriber, under the pain of disciplinary penalty in the event of a failure to do so and a mishap occurring."

Duty to query

Lord Fraser said he had no difficulty where the prescription was unclear or patently erroneous. However, he said, he would at some time have liked to explore the limits of the duty to query in the circumstances where there was no patent error but the dosage nevertheless appeared to be unusually large. He said it had been hinted to him that if the answer secured by the dispenser from the prescriber was not satisfactory the pharmacist might be in a position to refuse to dispense.

"I have my doubts whether that can be true in law," he said. The General Medical Council had traditionally been less stern on doctors who had erroneously prescribed than the Royal Pharmaceutical Society had on pharmacists who erroneously dispensed or failed to question the prescription, with the result that "pharmacists are regularly disciplined in cases where the original error lies with the doctor, who escapes any form of disciplinary sanction."

Nevertheless, the chairman continued, he would anticipate the medical profession would consider it a fallacious understanding of the respective duties incumbent upon prescriber and dispenser if the dispenser could, as a result of his or her professional assessment, to quote the Code, refuse to dispense at all.

The present case had nearly, but not quite, brought those issues into sharp focus, as Ms Hutton did not contact the prescriber. Despite having her own misgivings about the prescription, she had simply dispensed as prescribed. If she had made contact with the prescriber and had been told to mind her own business, or words to that effect, Lord Fraser said it was not entirely clear to him what would follow next. However, as she had made no query at all, the problem need not be pursued in the present case.

Lord Fraser said he expected to return to the issue if a similar case arose.

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Fraudulent prescription claims lead to striking off

A Leeds pharmacist who had been imprisoned after he consistently falsified prescription endorsements, resulting in almost £50,000 overpayment, has been ordered to be struck off the register by the Statutory Committee.

At its meeting on 11 December 2002 the committee inquired into the case of Bhupinder S. Bharj and Vemtech Ltd. Mr Bharj was the superintendent pharmacist and sole shareholder of the company, which operated a pharmacy at of 227 Dewsbury Road, Leeds, West Yorkshire.

Information had been received that on 14 June 2002 at Leeds crown court Mr Bharj had pleaded guilty to and been convicted on three counts of obtaining property by deception, for which he had been sentenced to six months imprisonment.

Mr Bharj was alleged to have obtained £8.894.47 overpayment in respect of claims made between October 1998 to September 2001. A further sum estimated to be almost £40,000 was alleged to have been obtained in respect of claims made between 1985 and 1998.

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

David Reissner, of Charles Russell (solicitors), represented Mr Bharj and the company. Mr Bharj did not attend the hearing

The committee heard that in June 2001 the NHS Counter Fraud Service examined the prescription account for Mr Bharj's pharmacy. It had been found that prescriptions for medicines supplied to a number of patients had been endorsed as if small packs had been supplied whereas larger packs had been issued. It was also found that, over the period October 1998 to September 2001, smaller quantities of the dispensed medicines had been ordered from wholesalers than had been claimed for. For example, 4389 bottles of Gaviscon Liquid 100ml had been claimed for but only 95 purchased; Mr Bharj would supply a 500ml bottle on a prescription but endorse it as if he had dispensed 5 x 100 ml. Over that period, it was calculated that £8,894.47 had been overpaid to Mr Bharj. However, Mr Bharj had admitted that he had been overclaiming since 1985; the fraud team had estimated that the total amount claimed and over paid amounted to an additional £39,778.27.

At his trial, the judge, passing sentence, had said, in relation to the £8,894.47 overpayment, that "This course of conduct over three years to deprive the pricing authority of almost £9,000 is such a serious thing for a pharmacist to have done that it calls for a custodial sentence. ... I cannot think of a higher level of trust than that which is vested in a pharmacist in his dealing with the NHS fund. ... I reject your [Mr Bharj's] protestation that you did not realise this was dishonest until it was all explained to you. You must have known you were depriving the fund dishonestly by cheating."

Mr Bharj had repaid the smaller amount; a sum of £25,201was being sought from him in settlement of the balance. The business is in the process of being sold.

Mr Bharj had previously had his name removed from the register in September 1994 following a conviction for unsupervised sale and allegations of professional misconduct including dispensing of a medicine other than that called for on a prescription. His name had been restored some 12 months later.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said that, even without the previous removal of his name, the matter which had been brought before them that day was so serious that the committee directed that Mr Bharj be struck off.

He was given three months in which to appeal.

No further action was taken against the company.

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Reprimand for pharmacist who supplied patient with date-expired tablets after removing expiry date

A Hull pharmacist who cut off the expiry date from dispensed tablets to conceal the fact that they had expired has been reprimanded by the Statutory Committee

At its meeting on 11 December 2002 the committee inquired into the case of John B. Sugarman, of 22 Nunburnholme Avenue, North Ferriby, North Humberside, and Regal Pharmacy Ltd. Mr Sugarman is the superintendent pharmacist and majority shareholder in the company, which operates a pharmacy at 475 Anlaby Road, Hull.

A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Sugarman had supplied a patient with medicines from which the expiry dates had been removed with the intention of obscuring the fact that the dates had passed. It was also alleged that Mr Sugarman had failed to ensure that all the medicines on the dispensary shelves in his pharmacy complied with the labelling regulations. Geoff Hudson, of Penningtons (solicitors) attended the meeting in order to present the facts of the case.

Denis Keegan, of Turner & Debenhams (solicitors) represented the company and Mr Sugarman, who was present at the hearing.

In respect of the first allegation, the committee heard that following a telephoned request, a patient's prescription for zafirlukast 20mg tablets was delivered to him at home on 25 October 2001. On opening the container, the patient found nine foil strips of tablets, six of which had been cut so as to remove the expiry date from the strips.

The patient complained to the Society and an inspector visited the pharmacy on 6 December to discuss the matter. While at the pharmacy, the inspector discovered a large number of medicines in white boxes without adequate labelling, a number of containers of medicines bearing patients' names and a carton of co-tenidone 50/12 tablets containing three strips of tablets, two of which were APS brand and one of Generics UK manufacture.

Interviewed

When interviewed by the inspector, Mr Sugarman had admitted that the supply of a patient's medicines with the expiry date removed did not represent a high standard of practice. He accepted that the expiry dates had been removed and admitted that that was an attempt deceitfully to obscure the fact that they had expired. He had said he regretted that he had not unequivocally admitted that he had cut off the dates.

He had also accepted that the failures in complying with the labelling regulations in regard to medicines on the dispensary shelves amounted to an appalling breach of standards in his pharmacy.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said that the failures in labelling of medicines on the dispensary shelves, taken on their own, would have been unlikely to have amounted to such serious misconduct as to render Mr Sugarman unfit to be on the register. Taken with the removal of the expiry date and the supply of date-expired tablets, however, that certainly did amount to such misconduct.

Further, it was not impressive that on repeated occasions over nearly seven years the inspector had had cause to complain about the organisation of Mr Sugarman's dispensary. While there had been some improvement in the past year, the organisation was not yet beyond all criticism. The committee appreciated that Mr Sugarman had a busy pharmacy but he had to ensure that he accorded a proper priority to safe and orderly arrangements in it.

It was, however, to his credit, continued the chairman, that Mr Sugarman had made a full and open admission of his failures and had expressed his remorse. He had also had compelling references and made a useful contribution to his local community.

The committee reprimanded Mr Sugarman but took no further action against the company.

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Striking-off after failings arising from alcohol problem

Repeated failure to fulfil his professional duties because of alcohol dependency led to a pharmacist being struck off the register by the Statutory Committee.

At its meeting on 10 December 2002 the committee resumed an inquiry into the case of Vinaykant Jayantilal Bhatt, of 8 Bernays Close, Stanmore, Middlesex.

The committee had considered at its meeting on 19 June 2001 complaints alleging that Mr Bhatt had been unfit to fulfil his professional duties as locum in charge of a pharmacy on 30 June and 4 July 2000 and that he had failed to honour locum bookings on 1 and 15 July 2000.

Geoff Hudson, of Penningtons (solicitors) attended the hearings to present the facts of the case to the committee.

Mr Bhatt was present and was represented by Ms Elaine Banton, of counsel, instructed by Gupta & Partners (solicitors).

At that June 2001 meeting, the committee ruled that Mr Bhatt had committed misconduct such as to render him unfit to be on the register. He had been shown to exhibit a pattern of increasingly erratic conduct against a background of alcohol abuse. The chairman (Lord Fraser of Carmyllie, QC) said that the committee had decided to adjourn its decision on the course of action to be taken until January 2002. Mr Bhatt had undertaken not to practise as a pharmacist without giving not less than 14 days written notice to the Pharmaceutical Society, to abstain from alcohol and to have his condition monitored. He had admitted that he had relapsed from abstinence in the past. The committee would want to see evidence from appropriate individuals so that the risk of any future relapse could be better assessed.

On resumption on 15 January 2002, the committee learned that Mr Bhatt had previously been removed from the register in 1996 for drink-related incidents, having been restored in 1999.

Lord Fraser said the committee had decided to postpone further its decision until the end of the year, conditional upon additional undertakings by Mr Bhatt. He would have to provide to the Society monthly reports of his medical and psychiatric condition, he should undergo blood tests every two months, and he should be allocated a care worker.

A fourth condition, said the chairman, was that Mr Bhatt should not undertake locum work but should find permanent employment with an employer willing to provide a regular report on his conduct.

If any relapse into alcohol dependency occurred, Mr Bhatt must inform the Society at once. Lord Fraser warned that if he withheld such information and it came to the Society's notice, the resumed hearing would be held forthwith and there was every likelihood the committee would remove his name from the register without further ado.

Failed to honour commitments

At the resumed inquiry on 10 December 2002, the committee also considered a complaint from the Council of the Royal Pharmaceutical Society alleging that Mr Bhatt, as a locum pharmacist, had failed to honour contractual commitments to a pharmacy company by failing to attend for work, as arranged, on a number of dates in June 2002, that while working alongside another pharmacist on 5 and 7 June 2002, he had smelled of alcohol and been slurred in his speech, and that he had failed to honour contractual requirements to another pharmacy company by not attending for work on 16 and 17 September 2002 and that his condition on 16 September had given the company's superintendent pharmacist cause to express concern about Mr Bhatt's fitness to practise.

Mr Bhatt attended the meeting and was represented by Jeffrey Skidmore, of Stuart Cohen & Mae (solicitors).

Giving the committee's decision, the chairman said the events complained of in June and September 2002 almost precisely replicated the misconduct which had caused his earlier appearance before the committee. He had repeatedly failed to honour contractual commitments without warning and had been drinking on pharmacy premises.

Such conduct was wholly unacceptable in a professional man. Mr Bhatt had repeatedly been given opportunities to put his alcohol problems behind him but, regrettably, he had failed to take those opportunities. He had said he would be prepared to give an undertaking not to practise as a pharmacist until he had put his alcohol problems behind him and would make every effort to achieve that. However, the committee could not, in the public interest, allow him to determine the time of his recovery.

The committee directed that his name should be removed from the register.

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

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Drink-related incidents lead to pharmacist’s striking-off

A Northumberland pharmacist who had been convicted of drink-driving offences and had been found unable to discharge her professional duties has been removed from the register by the Statutory Committee.

At its meeting on 12 December 2002 the committee inquired into the case of Lesley C. Davison, of Earsdon Moor House, Earsdon, Morpeth, Northumberland. Information had been received that on 19 December 2001, at South East Northumberland magistrates' court, Miss Davison had been convicted on four counts, all relating to an incident on 6 September 2001. She had been found guilty of driving a motor vehicle while over the prescribed limit of alcohol, driving without due care and attention, failing to stop after an accident and not giving her name and address. For those offences she had received a Community Rehabilitation Order for 12 months, ordered to pay compensation of £200 and costs of £50, and disqualified from driving for three years.

The committee had also received a complaint from the Council of the Royal Pharmaceutical Society alleging that, while engaged as a locum pharmacist in charge of a pharmacy in Peterlee, County Durham, Miss Davison's condition had been such that she was incapable of discharging her professional duties.

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

Miss Davison did not appear in answer to the notice of inquiry and was not represented. It was confirmed that the notice had been delivered to her address.

The committee heard, in relation to the Society's allegation, that on 21 August 2001, at 9am, Miss Davison arrived at the pharmacy at which she had been engaged as a locum and introduced herself. It was noticed at 9.10am by a dispensing assistant that she seemed incoherent and when bagging prescriptions, items were being omitted.

The assistant formed the impression that Miss Davison was intoxicated and contacted the area manger for the pharmacy company. When he arrived shortly afterwards he found Miss Davison to be speaking slowly but coherently. He did not smell alcohol on her breath and she denied being on any medication or having been drinking.

He sought permission to search her belongings and found a plastic bottle labelled "Alive Orange" containing a small amount of colourless liquid. He opened it and found it smelled of alcohol. After claiming the liquid was lemonade, Miss Davison eventually admitted it was indeed alcohol and that she had a problem.

The area manager then relieved her of her duties; he persuaded her not to drive home until later in the day. He also discussed the possibility of Miss Davison receiving counselling, and gave her telephone numbers for the Listening Friends Scheme and the Pharmacists Health Support Scheme.

Giving the committee's decision, the chairman (Lord Fraser of Carmyllie, QC) said the convictions and the incident at the pharmacy had been proved. They amounted to misconduct that rendered Miss Davison unfit to be on the register.

The committee ordered that Miss Davison's name should be removed.

She had three months in which to appeal.

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