Statutory Committee

Reprimand for record keeping and dispensing errors more

Reprimand for pharmacist in CD recording and storage offences case more

Warning about dispensing of unsigned prescriptions more

Man who was convicted of theft is allowed back on to the Register of Pharmaceutical Chemists more

Reprimand for record keeping and dispensing errors

A pharmacist who had made dispensing errors and a series of failures in the supply and recording of Controlled Drugs has been reprimanded by the Statutory Committee.

When it met on 21 July 2003 the committee heard the case of Adegboyega Bolarinwa Claudius Salako, of 22 Holmscroft Road, Limbury Mead. Luton, Bedfordshire. A complaint had been received from the Council of the Society alleging that, on dates between 4 January and 9 October 2002, while Mr Salako was proprietor of a pharmacy at 255 Birdsfoot Lane, Runfold Estate, Luton, he had been responsible for a number of breaches of the laws relating to supply and record keeping of CDs. He had failed to maintain an accurate and complete record of CDs purchased and supplied and had failed to endorse prescriptions with the date of supply.

Among other allegations were that, on 4 May 2000 and from December 2001 to 4 January 2002, Mr Salako had failed to comply with the Misuse of Drugs (Safe Custody) Regulations 1973 in relation to date-expired stock. Further, he had supplied lorazepam tablets against a prescription calling for loratadine tablets and had supplied replacement loratadine in a container bearing the wrong patient’s name, and in mixed batches without an explanation. He had also supplied 60 co-dydramol tablets against a prescription for 100. And there had been stock anomalies and inaccurate record keeping in respect of Ritalin tablets and of MST Continus 30mg tablets.

Geoff Hudson, of Penningtons (solicitors) presented the facts of the case to the committee. Mr Salako was present and was represented by Charles Apthorp, of counsel, instructed by Turner & Debenhams (solicitors).

The committee heard that on 4 January 2002, during a routine visit, one of the Society’s inspectors had found a number of discrepancies in relation to the Controlled Drugs register and CD stock. She found two bottles of methadone mixture dated 19 December 2001; they had been prepared for a patient who was prescribed 45ml methadone daily with two bottles on a Saturday. There were no corresponding entries in the register for the supplies on 2 or 3 January. The relevant prescription, however, had been endorsed with details of supplies made from 18 December 2001 to 5 January 2002. As the visit was on 4 January, that meant an endorsement had already been made for the next day.

It was also ascertained that five 10mg diamorphine ampoules could not be accounted for. On a white tray were various CDs with expiry dates going back to 1997, and it was impossible to see which were from stock, and needed to be destroyed in the presence of an authorised witness, and which were patient returns, for which witness destruction was not required. Finally, a stock bottle of methadone mixture was kept on a shelf in a lobby area.

As a result of those findings, the inspector revisited the pharmacy with the local police chemist inspection officer. They carried out a CDs stock check, destroyed date-expired drugs and discussed with Mr Salako a number of improvements he needed to make in handling CDs. However, when the police officer called again on 28 February 2002, he found that 56 MST Continus 10mg tablets dispensed on 24 January had not been entered in the “supplied” section of the register.

When the Society’s inspector next visited the pharmacy, on 30 July 2002, she again found discrepancies in the register and in the CD stock. The most important stock anomaly related to Ritalin. The purchase and supply records indicated that Mr Salako had supplied four more Ritalin tablets than he had purchased, and he had five tablets in stock. This indicated that he had nine more tablets than he should have had.

In August 2002 there had been a complaint about dispensing errors made at the pharmacy. Instead of receiving 100 co-dydramol tablets as prescribed, a patient had received only 60. On a prescription for her young son, who had been prescribed 28 loratadine 10mg tablets for hay fever, she was given 30 lorazepam 1mg tablets. Mr Salako had attempted to correct this error but was unable to retrieve the lorazepam when he delivered the correct medication; this, however, had been labelled with the wrong patient’s name. More errors had been discovered by the Society’s inspector on a visit on 9 October 2002.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC), noted that most of Mr Salako’s problems had arisen following a disastrous fire at his pharmacy in October 2000. He had had to close his premises for refurbishment until April 2001 and, being underinsured, had built up extensive debts. He had since tried, and failed, to sell the premises, and the lease had now expired. There appeared little likelihood of his resuming ownership of premises, even if he wanted to, and the committee would advise against that.

Mr Salako had indicated that he regretted the errors he had made and had produced good references. He hoped to be able to continue to work as a locum.

The committee reprimanded Mr Salako.

Reprimand for pharmacist in CD recording and storage offences case

The Statutory Committee has reprimanded a London pharmacist who had been fined for failures in his storage and record-keeping of Controlled Drugs.

At its meeting on 22 July 2003 the committee considered the case of Chandrakant Ramand Patel, of Pramuke Pharmacy, 486A Caledonian Road, London N7. Information had been received that on 24 October 2002, at Highbury Corner magistrates’ court, Mr Patel had pleaded guilty and been convicted of one count of failure to keep CDs in a locked safe, cabinet or room, contrary to the Misuse of Drugs (Safe Custody) Regulations 1973, two counts of failure to endorse prescriptions of methadone mixture 1mg/ml with the date supplied, and two counts of failure to enter in the appropriate register the receipt of three 500ml bottles of methadone mixture 1mg/ml as required by the Misuse of Drugs Regulations 2001; 106 similar offences were taken into consideration. Mr Patel was fined a total of £500 and ordered to pay £150 costs.

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

The committee heard that a police officer on a routine inspection visit to the premises in March 2002 found a considerable number of CDs that were not properly stored but were in a box in an upstairs room. Examination of the CD register brought to light the failures in recording supplies and receipts of methadone.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that the most disappointing feature of the case was that it was only on the police officer’s visit in March 2002 that Mr Patel’s wide range of failure to observe the regulations was first noted. Astonishingly, when the police officer revisited the premises in June 2002, little or nothing had been done to effect any improvement. That was a considerable failure to observe the law.

Mr Patel’s serious misconduct was such as to render him unfit to be on the register. There were, however, said the chairman, a number of mitigating factors. His efforts to modernise his pharmacy in the face of a hostile neighbour and a less than satisfactory rate for completion of building work affected him and the running of his pharmacy: not least, his Controlled Drugs cabinet had to be moved. And during the same period Mr Patel and his wife suffered a number of distressing domestic crises.

Mr Patel had said that his records and register were now in order. However, the committee wanted to be confident that everything was now in the best working order and records were accurately kept. It had no information about the premises since the police visit in June 2002. The committee therefore adjourned the hearing for six months, requesting that a Society inspector should make an unannounced visit during that period.

When the case came back to the committee on 29 January 2004, the committee learnt that nothing adverse had been reported by the inspector or the police officer, and restricted its sanction to a reprimand.

Warning about dispensing of unsigned prescriptions

A pharmacist who allowed himself to “drift” into the practice of dispensing unsigned prescriptions has been given strong advice from the Statutory Committee. The committee took no further action against him or his company.

At its meeting on 22 July 2003, the committee inquired into the case of Maurice Anthony Waldman, of 7 Bradfield House, Repton Park, Woodford Green, Essex, and Maurice Anthony Ltd. Mr Waldman is a director and superintendent pharmacist of the company, which owns Waldmans Pharmacy, 6 Chelmer Village Centre, Chelmsford.

A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Waldman had dispensed chloramphenicol eye-drops for a patient against an unsigned prescription. It was further alleged that he had an agreement with a local doctor’s surgery that unsigned prescriptions could be directed to his pharmacy for dispensing.

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

Denis Keegan, of Turner & Debenhams (solicitors) appeared on behalf of Mr Waldman and the company. Mr Waldman was present.

The committee was told that towards the end of 2001, when a local GP fell ill, arrangements were put in place whereby the doctor’s surgery directed patients to the pharmacy to have their unsigned prescriptions dispensed.

On 17 December 2001, the mother of a sick child, who had been seen by the doctor on 14 December, attempted to make an appointment with the doctor for the child, whose condition had worsened. She was unable to see the doctor but a receptionist said she would write out a prescription for collection later that day. When she returned, she was handed an unsigned prescription and told to take it to Waldmans Pharmacy, where it would be dispensed. The mother, with her child, took the prescription to the pharmacy and handed it to an assistant, pointing out it was unsigned. She was told it could be dispensed and that such prescriptions were sent back to the surgery for signature at a later date. Mr Waldman did not examine the child or make any comment when handing out the prescription.

When the matter was being investigated, it came to light that three other unsigned prescriptions had been submitted to the Prescription Pricing Authority during the same month. When interviewed by one of the Society’s inspectors on 13 March 2002, Mr Waldman had confirmed that the GP’s surgery had asked him to “help patients on his [the GP’s] behalf” during his sickness. The practice nurse or receptionist would telephone Mr Waldman and tell him what medication was required and he would decide whether or not to dispense it. Unsigned prescriptions would be returned to the surgery for signature.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that Mr Waldman had admitted dispensing the eye-drops on an unsigned prescription. He had said he had heard the child’s mother telling an assistant that she had come from a surgery where he knew the doctor was not always available, through ill-health, and thought she had said it was a repeat prescription, as did his assistant. The mother, however, denied she had said that. There were conflicting versions of what transpired in the pharmacy that evening but neither Mr Waldman’s nor his assistant’s evidence had been significantly shaken, said Lord Fraser.

There had been no formal arrangement to dispense unsigned prescriptions. Rather, the pharmacy had drifted into the arrangement into, and had done so for the benefit of patients. The point had been made that three unsigned prescriptions in the hands of the PPA were not evidence of such an arrangement. They were simply errors on Mr Waldman’s part, and had just “slipped through”. As he had pointed out, if there had been an arrangement, as originally alleged, he would have returned the prescriptions to the doctor for signature before submitting them to the PPA.

Mr Waldman’s dispensing of the eye-drops on an unsigned prescription, and the arrangement with the GP into which he had allowed himself to drift, amounted to misconduct, said the chairman, but not such serious misconduct as to render him unfit to be on the register.

In deciding to take no further action , the chairman strongly advised Mr Waldman not to allow his pharmacy to drift into the practice of dispensing against unsigned prescriptions, however much he regarded it as being in the interests of patients.

Man who was convicted of theft is allowed back on to the Register of Pharmaceutical Chemists

The Statutory Committee has granted an application for restoration to the register by a man whose name had been removed for theft.

When it met on 22 July 2003 the committee heard an application for restoration to the register from Vijay Kumar Bansal, of 22 Mansfield Drive, Hayes, Middlesex.

Geoff Hudson, of Penningtons (solicitors) presented the facts of the case to the committee. Mr Bansal attended the hearing and was represented by David Reissner, of Charles Russell (solicitors).

The committee heard that Mr Bansal had been removed from the register in February 2001 following a conviction for theft.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC), said the case was in many respects a tragic one. Mr Bansal had begun his career in the most dramatic and emphatic of fashions. He was talented at university, having secured a first-class degree and a prize as student of the year. Regrettably, some time later he was involved in a serious breach of trust vested in him by his employers, resulting in the removal of his name; the consequences for him subsequently had been very serious indeed.

The chairman said that the committee had considered the references put forward on Mr Bansal’s behalf and, most particularly, that of his present employer, who said specifically that he regarded Mr Bansal as trustworthy. The community service officer was also comparably complimentary about him.

The committee directed that Mr Bansal’s name should be restored to the register.