Statutory Committee

Error in dispensing morphine tablets leads to Statutory Committee reprimand for pharmacist more

Pharmacist dispensed wart ointment instead of nasal cream more

Error in dispensing morphine tablets leads to Statutory Committee reprimand for pharmacist

The Statutory Committee has reprimanded a pharmacist who dispensed a wrong strength of morphine sulphate tablets, with the result that the patient required medical attention.

At its meeting on 8 May 2003, the committee inquired into the case of Narendra Patel, of 5 Jervis Park, Sutton Coldfield, West Midlands. Mr Patel is the superintendent of N. D. Chemists Ltd and was the regular pharmacist in charge at one of its pharmacies, at 374–376 College Road, Birmingham.

The Council of the Royal Pharmaceutical Society had made a complaint alleging that on 8 July 2002 Mr Patel had wrongly supplied MST Continus 30mg tablets instead of 10mg tablets. He had failed to admit the error when the patient’s daughter had inquired and had failed to recommend that the patient should seek medical advice. It was further alleged that he had failed to contact the patient’s doctor despite knowing that the patient had taken some of the higher strength tablets. In addition, he had put back into stock, and subsequently redispensed, the returned MST tablets.

Geoff Hudson, of Penningtons (solicitors) appeared before the committee to present the facts of the case. Philip Grey, of counsel, instructed by Axis Solicitors, represented Mr Patel, who attended the inquiry.

The committee heard that on 29 June 2002 a locum pharmacist had dispensed a prescription for 100 MST Continus 10mg tablets at the College Road pharmacy. Forty 10mg tablets were supplied and an owing slip provided for the balance of 60.

On 8 July, when Mr Patel was the pharmacist in charge, he erroneously dispensed 60 tablets of 30mg strength. He realised his error the following morning and sent a driver to collect the tablets and substitute 10mg tablets. When the driver returned, Mr Patel noticed that eight 30mg tablets were missing from the 60 dispensed. He asked the driver if the patient had been all right and was told she had.

At no stage did Mr Patel telephone the patient or attempt to contact the prescriber. When the patient’s daughter telephoned to ask whether the wrong tablets had been dispensed, he had not admitted the error but told her it had simply been a “wrong box” and there was nothing to worry about. The daughter nevertheless contacted the patient’s doctor, who visited his patient and had her admitted to hospital for observation.

Subsequently, Mr Patel had admitted his error to the police chemist inspection officer and received an informal caution. Interviewed by one of the Society’s inspectors on 4 September 2002, he said he had panicked and had not handled the situation correctly.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said the Society’s complaint related to a single, but serious dispensing error. It was not clear exactly how many tablets the patient had taken, but she had clearly taken more than intended. After the beneficial effect of a good night’s sleep, the next day she was “spaced out”, in the words of her daughter, later becoming nauseous and breathing slowly. As a result, the patient received an injection from her doctor and was sent for observation to a hospital.

Although Mr Patel had assumed, or ought to have assumed, that she had taken all eight of the missing 30mg strength tablets — ie, 240mg of tablets in 24 hours instead of the prescribed 40mg in 24 hours — he had taken no steps to secure medical advice for her and, worse still, he had lied to her daughter when she had queried the supply.

“His conduct may have been prompted by panic”, said the chairman, “but, as I think he recognised himself, that is quite unacceptable conduct in pharmacists”. The committee found the Council’s allegations established.

In Mr Patel’s favour, Lord Fraser continued, he had been completely open about the matter both with the police and the Society’s inspector. He had good references. And at the time he had been affected by unfortunate personal circumstances; although that was not an excuse, it had resulted in a loss of confidence.

The committee reprimanded Mr Patel.

Pharmacist dispensed wart ointment instead of nasal cream

The Statutory Committee has adjourned its decision in a case in which a London pharmacist dispensed an ointment for removing warts on a prescription calling for a nasal cream.

At its meeting on 6 May 2003 the committee inquired into the case of Obiajulu Ejiofor, of 20 Chestnut Grove, West Norwood, London. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mrs Ejiofor had supplied Posalfilin ointment against a prescription ordering Naseptin cream and had failed to contact the prescriber when alerted to the error. It was also alleged that she had failed to respond to a letter of complaint from the patient.

The facts of the case were presented by Geoff Hudson, of Penningtons (solicitors).

David Aaronberg, of counsel, instructed by Turner & Debenhams (solicitors) represented Mrs Ejiofor, who was present at the hearing.

The committee heard that on 10 April 2002, Mrs Ejiofor had been the proprietor and pharmacist in charge of a pharmacy known as Specky-Tin at 52 Vassall Road, London SW9. On that day, a patient had presented a prescription for Naseptin cream 15g. Mrs Ejiofor had dispensed Posalfilin ointment and labelled it as if it were Naseptin. She gave it to an assistant to hand to the patient, who was given no advice or information. Posalfilin was a treatment for plantar warts and not suitable for application to the face.

The patient began to use the ointment on the same day and continued for the next five days. As a result, her nose became burned, inflamed and swollen. On 16 April she realised she had not been given Naseptin and returned to the pharmacy. She showed the tube of Posalfilin to Mrs Ejiofor, who took it from her and exchanged it for Naseptin, having peeled off the label from the Posalfilin and applied it to the Naseptin. She advised using cotton wool and water to clean out the nose. The patient said that the medication had also given her a sore throat; Mrs Ejiofor had given her a bottle of Oraldene for that. She had not contacted the prescriber but advised the patient to see the doctor as soon as possible. The patient had written to Mrs Ejiofor on 18 April seeking an apology, but had not received a reply.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that Mrs Ejiofor had made and admitted a serious dispensing error that could have had severe consequences. The consequences that had occurred had been, to say the least, unpleasant and painful.

The committee was concerned that the patient’s letter should have been received at the pharmacy but not read until the patient came in a week later, angry at the lack of a response.

Lord Fraser said that the misconduct established was such as to render Mrs Ejiofor unfit to be on the register. Had she still owned the pharmacy and wished to continue to work there, the committee would have had serious doubts about allowing her to remain on the register. However, she had sold the premises and was now employed as a locum.

The committee had decided to adjourn the case for a year. At the resumed hearing, references would be required from Mrs Ejiofor’s employers during that time. If they were satisfactory and there had been no further dispensing errors or other problems, the likely outcome of the case would be a reprimand. But, warned Lord Fraser, that should not be considered the inevitable outcome. If there were further problems, the only safe course would be to require the removal of Mrs Ejiofor’s name from the register.