Statutory Committee

Dispensing of wrong strengths results in reprimand more

Reprimand for pharmacist after a series of Controlled Drugs errors more

Refusal to accept warning leads to Statutory Committee appearance more

Restoration to register granted subject to a number of conditions more

Pharmacists warned that they risk being struck off if they fail to keep their CD registers up to date more

Pharmacist reprimanded for failures in working procedures more

Dispensing of wrong strengths results in reprimand

The Statutory Committee has reprimanded a locum pharmacist who repeatedly dispensed products of the wrong strength.

At its meeting on 19 June 2003 the committee inquired into the case of Frank Harvey Lawton, of 70 Woodstock Drive, Ickenham, Uxbridge, Middlesex. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that 30 March, 2002 and on 19 April 2002 Mr Lawton had made errors in dispensing that could amount to professional misconduct.

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

Mr Lawton attended the inquiry and was represented by Lisa Sinclair, of counsel, instructed by Davies & Partners (solicitors).

The committee heard that the alleged errors had taken place on two dates while Mr Lawton was locum pharmacist in charge of pharmacies at 195 London Road, Reading, and 534 Northumberland Avenue, Reading. Both were at the time owned by John Robertson Butler & Son Ltd.

On 30 March 2002, when Mr Lawton was working at the London Road pharmacy, he dispensed a prescription that included bendrofluazide tablets 2.5mg, co-codamol effervescent tablets 30/500 and Prothiaden capsules 25mg. The medicines were labelled as if the correct medicines had been supplied and handed out to the patient’s husband. Mr Lawton later realised that he had dispensed Prothiaden tablets 75mg and telephoned the patient, asking her to return the wrongly dispensed item. He left a message at the pharmacy to say what he had done.

The next day, the patient returned the Prothiaden, taking also the other items. The pharmacist then on duty, Rajin Patel, decided to check them all and saw that co-codamol effervescent tablets 8/500 and bendrofluazide tablets 5mg had been dispensed in error for the strengths prescribed; a fourth item was correct. He replaced the incorrect items.

On 19 April, when Mr Lawton was pharmacist in charge at the Northumberland Avenue premises, he supplied on a prescription calling for bisoprolol tablets 10mg and labelled as such, bisoprolol 5mg. When the patient began to take the tablets, his angina attacks increased. He arranged to consult his doctor and at that time noticed that he had received the lower strength of bisoprolol.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that in the first incident, Mr Lawton had noticed his error in respect of the Prothiaden shortly after the patient’s husband had left the premises. He acted properly in telephoning to alert the patient to the error. The accounts of the patient and her husband coincided with each other and with the service incident report filled out by Mr Patel when the medicines were returned. That was when the other two errors were discovered. Mr Lawton, said the chairman, had not accepted that account. He said he had noticed all three errors on the day in question and had expected a pharmacy assistant to take all three corrected prescriptions to the patient. The committee, however, preferred Mr Patel’s version of events — that is, that Mr Lawton had noticed only one error.

Turning to the bisoprolol incident, the chairman said that the committee was not happy with an attempt by Mr Lawton to “blacken” the conditions at the Northumberland Avenue pharmacy. He had made no complaint at the time, first mentioning the pharmacy conditions when the superintendent pharmacist had raised the dispensing error with him. This was in spite of the fact that it was clearly set out in the Code of Ethics that pharmacists should not work in conditions that might interrupt the clinical pharmaceutical decisions they might have to take. And Mr Lawton had been “less than fulsome” in his explanations to the Society’s inspector, the Society itself and to the committee.

Nevertheless, continued the chairman, Mr Lawton had had a long and distinguished career in pharmacy. He should perhaps reflect whether, at this late stage, he should undertake even limited locum work.

The committee found the dispensing errors established and reprimanded Mr Lawton.

Reprimand for pharmacist after a series of Controlled Drugs errors

A series of errors on a single day, relating to the dispensing of Controlled Drugs, has led to a reprimand for a Sheffield pharmacist.

At its meeting on 18 June 2003 the Statutory Committee inquired into the case of Victor Taiwo Solola, of 209 Hartley Brook Road, Sheffield. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Solola had made a number of errors in the supply or recording of Controlled Drugs.

Geoff Hudson, of Penningtons (solicitors) presented the facts of the case to the committee. Mr Solola was present but not represented.

The committee heard that on 22 October 2002 Mr Solola had dispensed 100ml of methadone mixture 1mg/ml against a document purporting to be a prescription issued by the Ripple Project, which offers medical services to drug users. But it was a forgery, and the Ripple Project did not hold details of the person named. Mr Solola did not know the patient or the purported prescriber, whom he had assumed to be a “Dr Ripple”. He had made an entry to that effect in the methadone register.

On the same day, Mr Solola had altered a CD register entry relating to the dispensing of 35ml Physeptone mixture 1mg/ml. The alteration rendered the relevant details illegible. Further, a prescription for methadone dispensed on that day had not been entered in the register and an instalment of methadone mixture 1mg/1ml had been made to a patient otherwise than in accordance with the prescriber’s directions.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that the Society argued that Mr Solola should not have dispensed the purported Ripple Project prescription because a patent error should have alerted him to the possibility of forgery. It called for 50ml twice a day and had given a total for the week of 350ml instead of 700ml. It was true that the doctor’s signature was effectively illegible, but that was not an unusual feature of GPs’ prescriptions.

With regard to the altered entry in the CD register, Mr Solola had said he made the alteration after realising he had made an error. But Section 20 of the Misuse of Drugs Regulations 2001 stated: “No cancellation, obliteration or alteration of any such entry shall be made and a correction of such an entry shall be made only by way of marginal note or footnote which shall specify the date on which the correction is made.” Mr Solola admitted having breached that requirement; the committee did not regard the incident, although undoubtedly a breach, as a particularly significant one.

Turning to the failure to make a CD register entry relating to methadone dispensed on 22 October, the chairman said that the regulations gave a pharmacist leeway to make an entry not only on the day of dispensing but also on the next day following. The error was picked up on 23 October, a day on which Mr Solola was not working at the pharmacy, by another pharmacist. Mr Solola had acknowledged it was an oversight on his part.

In the final instance, a patient with a prescription for three days’ supply of methadone, requiring to be dispensed on 21 October, arrived at the pharmacy too late to collect it and returned the following morning. Mr Solola dispensed the full three days’ supply, entering it in the register as having been dispensed on 21 October. He explained that he had done this because it had been made up on 21 October, which was true. What he should have done, said the chairman, was refuse to dispense at all for the three days and send the patient back to his doctor to secure a new prescription.

All those incidents, occurring on one day, amounted to misconduct such as to render Mr Solola unfit to be on the register. However, the committee concluded that he should instead be reprimanded. He was strongly advised to re-examine carefully all that was required of a pharmacist in relation to CDs.

Refusal to accept warning leads to Statutory Committee appearance

A locum pharmacist’s refusal to accept a warning after a complaint of inappropriate behaviour in dealing with a patient led to his “unnecessary” appearance before the Statutory Committee.

At its meeting on 17 June 2003, the committee inquired into the case of Emanuel Winer, of 41 Clissold Court, Greenway Close, Green Lanes, London N4. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Winer had failed to accept that, as pharmacist in charge of a pharmacy, he was professionally and legally accountable for any medicines supplied from the pharmacy; and that he had made inappropriate responses to a warning as to his future conduct issued by the Infringements Committee.

Fenella Morris, of counsel, instructed by Penningtons (solicitors), presented the facts of the case.

Mr Winer attended the meeting. He was not represented.

The committee heard that while Mr Winer was employed as a locum pharmacist at a Safeway branch in Loughton, Essex, on 17 January 2002, contraceptive tablets prescribed for a patient had been handed out to the wrong person. When the patient who had left the prescription for dispensing returned to collect it, she was at first told it was not ready. Eventually, Mr Winer had told her he did not know what had happened to her medicine and suggested she take the prescription elsewhere to be dispensed because the pharmacy had no more in stock.

The patient was not happy with the way Mr Winer had handled the matter and wrote to the Society to complain. Subsequently, a written warning as to his future conduct had been sent to Mr Winer on behalf of the Infringements Committee. In response, he wrote that he personally had not made a dispensing error and that he was not prepared to accept any criticism in the matter. He would, he said, have expected the Society to inform the complainant that the matter was one purely of customer relations that should not have been brought to the Society’s attention.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that the patient had been reluctant to take the prescription elsewhere; she had had a long day and wanted to get home to her child, who was with a babysitter. Further, from what Mr Winer had said she had taken that her prescription had already been dispensed, with the implication that she was waiting for a second quantity of medication. Rightly or wrongly, she had felt this was an imputation of dishonesty on her part. She left the premises after 70 minutes, still without her prescription.

Subsequently, it transpired that the prescription had been erroneously dispensed by an inexperienced assistant and handed to another woman. The error, said the chairman, was one for which Mr Winer, as pharmacist in charge had to take responsibility.

Although Mr Winer had been reluctant to take responsibility for the original mistake, once it had been discovered he acknowledged that it was incumbent upon him to take steps to ensure that the wrong recipient did not take the tablets and seek to ensure that the prescription was then returned to the pharmacy. All those things he had done properly. However, Mr Winer could not sidestep his responsibility as the pharmacist under Section 71(i)(a) of the Medicines Act 1968. That was the Society’s central complaint against him and the committee found it established.

The chairman said the patient’s complaint was not so much about the error as about Mr Winer’s attitude towards her at the time. She said that he had begun to “flap his arms” and shout and had pushed past her. She thought his conduct totally unacceptable in a professional person.

For his part, Mr Winer had disputed her version of events. He had claimed not to have known of it until recently. However, one of the Society’s inspectors had told him what the patient was alleging as long ago as 22 February 2002. He had contradicted it at that time.

The committee accepted the patient’s account as truthful. Mr Winer’s denial, said the chairman, had been “heated but not particularly illuminating”. More importantly, Mr Winer accepted that if the patient’s account of what had happened was true, such conduct would be unacceptable in a professional person. It followed that his behaviour, even by his own standards, had been unacceptable.

The committee was also concerned that Mr Winer had apparently considered the dispensing error as “only a matter of customer relations”.

Furthermore, continued Lord Fraser, Mr Winer seemed to think that the role of the Royal Pharmaceutical Society was to protect him in the face of a complaint from a member of the public. “On the contrary, in our view the Society’s role is properly that of the protection of the public, the public interest and the upholding of professional standards.” After the hearing, he now understood that more clearly.

The Infringements Committee had, rightly, decided to deal with the matter by issuing a non-statutory warning. That was appropriate to the dispensing error, the correction of the error, and Mr Winer’s rudeness to a long-suffering patient. But Mr Winer had refused to accept the warning and the case had therefore — unnecessarily — come before the Statutory Committee. The committee decided that no further action should be taken in the matter.

Restoration to register granted subject to a number of conditions

A man who was struck from the register for illegally selling a large quantity of temazepam has been allowed to have his name restored subject to his observation of several conditions.

At its meeting on 23 July 2003 the Statutory Committee heard an application for restoration from Paresh Samani, of 14c Esterbrooke Street, London SW1. Mr Samani had been struck off in April 1994 following a conviction for illegally selling 585,000 temazepam tablets; he had been sentenced to 12 months imprisonment.

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

David Reissner, of Charles Russell (solicitors) appeared on behalf of Mr Samani, who was present at the hearing.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that Mr Samani had previously had an addiction to cocaine but had not taken any since his conviction. Over the ensuing few years, he had undertaken a variety of activities but, regrettably, had had an addiction to alcohol.

During May 2001, as a result of excessive consumption of alcohol, Mr Samani had had an accident in his bath and had sustained severe burns, for which he had undergone painful treatment. From that time, there seemed to have been a significant change in his life and the committee accepted that he had not consumed alcohol since then.

The committee had decided to allow the restoration of Mr Samani’s name to the register. In doing so, said the chairman, he would be asked to observe a number of conditions over the next two years.

The first condition was that Mr Samani should submit blood tests that demonstrated he was free of both alcohol and narcotics.

The second condition was that Mr Samani should agree to work only in situations where he was not at all times the pharmacist in charge.

The third condition was that Mr Samani should continue to receive counselling and maintain contact with any support organisations his counsellor recommended.

In giving Mr Samani a further chance, said Lord Fraser, the committee hoped he would not abuse the trust vested in him. That would be regarded very seriously indeed if he were to come before the committee again.

Pharmacists warned that they risk being struck off if they fail to keep their CD registers up to date

Pharmacists have been warned by the Statutory Committee that they risk being struck off if they fail to keep their Controlled Drugs registers up to date. The committee reprimanded a London pharmacist who had been fined after failing to do so.

At its meeting on 21 July 2003, the committee inquired into the case of Anil Keshavlal Devshi Shah, of 17 Kelvin Crescent, Harrow, Middlesex. Mr Shah was the occupier and manager of Dearcare Pharmacy, 35 Richmond Way, London W14. Information had been received that on 8 July 2002, at Blackfriars Crown Court, Mr Shah had confessed to, and been convicted, of eight counts of failing to comply with regulations made under the Misuse of Drugs Act 1971. He had been sentenced on 16 August 2002 and fined a total of £750, with £195 costs.

Geoff Hudson, of Penningtons (solicitors) presented the facts of the case to the committee. David Aaronberg, of counsel, instructed by Charles Russell (solicitors), represented Mr Shah, who attended the inquiry.

The committee was told that two of the offences related to failure to ensure that Controlled Drugs, namely methadone mixture and Rohypnol tablets, were kept in a locked safe, cabinet or room. The remaining six concerned Mr Shah’s failure to make entries in the Controlled Drug register of the supply of methadone, on 20, 21 and 22 December 2000, to six different patients, on the day of supply or the next following day. The latter six charges were said to be specimen charges.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that at Mr Shah’s trial it was apparent that, if the presiding judge had been able to impose more than a simple fine of £750, and impose a separate fine for each charge, she would have preferred to do so.

The judge had described the offences as very serious, said Lord Fraser, and the committee adopted the same attitude. He continued: “Pharmacists across the country should recognise how close they would come to imperilling their careers if they fail to do what the law requires, and fail to keep the registers required under the regulations up to date, and make the entries on the day, or on the next day.” The committee, he said, was growing weary of repeating that injunction to pharmacists.

There was now a greater degree of co-ordination in such matters between police forces across Britain and the Society, said the chairman, and that was welcomed. However, he had no clear idea when a failure to make an entry in a register was something to be dealt with by the Society’s inspector and reported to the Society, or was to be taken forward by the police with a view to securing a conviction in court. A more clearly defined separation of functions would be helpful.

Mr Shah’s conviction was such as to render him unfit to be on the register. However, he had already been penalised by the courts and the offences had caused no injury to patients and no Controlled Drugs had been released into the community; and Mr Shah had been ill at the time. The committee also took into account the fact that the first offence related to December 2000 and the hearing was taking place near the end of July 2003.

The committee reprimanded Mr Shah.

The chairman reiterated his warning that pharmacists must appreciate how close they came to having their names removed from the register if they continued to fail to keep their registers up to date as required by law.

Pharmacist reprimanded for failures in working procedures

A London pharmacist who had failures in his working procedures and had dispensed an outdated medicine has been reprimanded by the Statutory Committee.

At its meeting on 23 July 2003 the committee inquired into the case of Ghanshyam Magenbhai Patel, of 288 Princes Road, Kingsbury, London NW9. Mr Patel is the proprietor and pharmacist-in-charge of Bachus Chemist, 708 Kenton Road, Kenton, Harrow, Middlesex.

A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that, after being given advice by a Society inspector, Mr Patel had, inter alia:

· Dispensed date expired Erythroped A 500mg tablets on 4 September 2002, failed to ensure that those tablets had been labelled with the cautionary and advisory labelling recommended by the current British National Formulary, and failed to document the supply of the date expired tablets;
· Failed to take adequate remedial action after being informed he had dispensed a date expired medicine;
· Failed to implement a complaints procedure and error/incident log;
· Failed to keep adequate records of refrigerator temperatures and to ensure that thermolabile substances were being stored at a temperature between 2C and 8C;
· Failed to update computer software with the advisory and cautionary labelling as required in the BNF;
· Failed to label a short-life product with an appropriate expiry date; and
· Failed to be aware of the requirements for, and to keep records of, extemporaneously prepared products and specials.

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

Denis Keegan, of Turner & Debenhams (solicitors) represented Mr Patel, who attended the inquiry.

The committee heard that after a routine visit to Mr Patel’s pharmacy on 23 October 2001, one of the Society’s inspectors had left an advice note setting out concerns about drugs, refrigerator monitoring, procedures for dealing with dispensing errors and records required for extemporaneously prepared medicines and specials. When she returned to the pharmacy on 24 January 2002, she found the refrigerator had been replaced but was being operated at too low a temperature. She also noted that the pharmacy had no written complaints procedure. The Society had subsequently written to Mr Patel requiring him to make certain improvements.

The inspector revisited the pharmacy on 7 October 2002 after the receipt of a complaint from a patient who had received out-of-date Erythroped tablets on a prescription. The inspector found date-expired stock in the dispensary and short-dated items in the shop area. The refrigerator temperature was still below zero and a box of insulin was frozen. There was no formal written or documented procedure for date checking the stock and poor practice in relation to advisory and cautionary labels of dispensed medicine: the computer had not been kept up to date with the appropriate labelling requirements.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that the Society’s allegations against Mr Patel had been found proven and his conduct was such as to render him unfit to be on the register. However, evidence had been submitted that he was undertaking a series of continuing education courses and that all the deficiencies complained of, including the refrigerator and computer problems, had been remedied. On a recent visit, the inspector had found arrangements in the pharmacy to be good.

It had been said on Mr Patel’s behalf that the Statutory Committee proceedings would have been “a serious wake-up call”. “I certainly hope he regards it as such”, said Lord Fraser.

The committee reprimanded Mr Patel.