The Pharmaceutical Journal
Vol 272 No 7283 p86
24 January 2004

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  Prescription checking
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Letters to the Editor

Dispensing errors

Not a new hazard

From Mr P. Penson

Until recently, I was under the impression that dispensing errors were a relatively new hazard, however a letter in The Times for 15 January alerted me to the following epitaph found on a gravestone in Hillswick, Shetland.

It read:

“Donald Robertson. Born 14th January 1785, died 4th June 1848. He was a peaceable, quiet man, and to all appearances a sincere Christian. His death was much regretted, which was caused by the stupidity of Laurence Tulloch, who sold him nitre instead of epsom salts, by which he was killed in the space of five hours after taking a dose of it.”

I wonder what the Statutory Committee would have made of Mr Tulloch and whether if clinical governance had been in place, the error would have been avoidable.

Peter Penson
Fourth-Year Student
Welsh School Of Pharmacy,
Cardiff

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