Pharmacist reprimanded for errors in methadone supply
and recording
The duty incumbent upon pharmacists to properly maintain the Controlled
Drugs register was emphasised when the Statutory Committee reprimanded
a pharmacist for failures in the supply and recording of methadone.
When it met on 18 June 2003, the committee considered the case of Anthony
Christopher Lawlor, of 109 Station Road, Wylde Green, Sutton Coldfield,
West Midlands. A complaint had been received from the Council of the
Royal Pharmaceutical Society alleging that, on dates between August 2000
and January 2001, Mr Lawlor had made advance supplies of methadone otherwise
than in accordance with the prescriber’s instalment directions,
had failed to maintain an accurate Controlled Drugs register and had
failed to endorse prescriptions correctly.
Geoff Hudson, of Penningtons (solicitors), presented the facts of the
case on behalf of the Society.
Denis Keegan, of Turner & Debenhams (solicitors), appeared on behalf
of Mr Lawlor, who attended the inquiry.
The committee heard that Mr Lawlor, in partnership with his wife, owned
a pharmacy at 24 Church Road, Aston, Birmingham, which did not open on
Saturdays or Sundays. An examination of the prescriptions for two named
patients had revealed a number of irregularities in the supply and recording
of methadone, in breach of the Misuse of Drugs Regulations 1985.
Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie,
QC) said that the closure of Mr Lawlor’s pharmacy on Saturdays
or Sundays was in part the cause of some of the problems that had arisen.
An addict’s prescription regularly brought to the pharmacy was
for a daily supply of methadone mixture, with two days’ supply
to be issued on the Saturday. However, because the pharmacy was not open
at the weekend, Mr Lawlor would dispense three days’ supply on
the Friday. He told the committee this had been done with the verbal
agreement of the prescribing doctor.
Although there was some evidence for such an agreement, said the chairman,
Mr Lawlor did not seek consent on every occasion. He assumed that, having
been given once, consent would be forthcoming again. However, a verbal
variation of the prescription was not sufficient: “A new written
prescription must be secured if weekend supplies are to be dispensed
on a Friday and not a Saturday”, emphasised Lord Fraser. On at
least eight occasions between October 2000 and January 2001 the addict
had been given three days’ supply on a Friday.
Further, the chairman continued, although it was required that such prescriptions
were endorsed with the date the supply was made, Mr Lawlor had endorsed
each prescription as if the supply had been made on the day specified
by the prescriber instead of the days on which it had actually taken
place.
There were also irregularities in the Controlled Drug register entries
relating to the methadone supplies. Mr Lawlor had made 94 separate supplies
of methadone to the addict but had made only 23 entries. Of those, the
chairman noted, only eight had given the same details as the endorsements
on the prescriptions to which they were supposed to relate. The CD register
entries had been made on the occasion of the first day’s supply
but had related to the full quantity called for by the prescription.
In one instance, a prescription had been endorsed to show 12 separate
supplies but there was no corresponding entry whatsoever in the register.
There was a “similar sorry tale” in relation to methadone
supplies to another patient, the chairman added.
The matter of a prescription entered into the CD register with the wrong
date was not particularly significant considered against the other errors.
Those, said Lord Fraser, were much more serious and were regarded by
the committee as amounting to misconduct such as to render Mr Lawlor
unfit to be on the register.
However, continued the chairman, Mr Lawlor had had to learn a salutary
lesson that had caused him considerable distress over the past two-and-a-half
year, not least because he had faced criminal charges, which were ultimately
dismissed. The committee was satisfied that he had learnt his lesson.
Recent visits by one of the society’s inspectors had found his
CD register in order. Mr Lawlor was reprimanded.
The chairman emphasised that a CD register was not kept just for a pharmacist’s
internal recording purposes but for a wide range of law enforcement authorities.
Parliament had ordained the precise terms on which it should be kept.
A pharmacist who failed to maintain the register as required by the law
was subject to a possible criminal law penalty. Those who came before
the Statutory Committee for such a failure had to recognise the peril
it might do to their careers.
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