Statutory Committee

Catalogue of dispensing errors leads to striking-off more

Pharmacist reprimanded after taking medicines for own use more

Reprimand for pharmacist who failed to take appropriate action after patient injected adrenaline that had been dispensed in error more

Restoration decision postponed in case of pharmacist struck off for Viagra offences more

Catalogue of dispensing errors leads to striking-off

A Kent pharmacist has been struck off the register by the Statutory Committee after being responsible for a “catalogue of errors” in dispensing over a decade.

At its meeting on 9 December 2003 the committee inquired into the case of Bharatkumar Ramanbhai Patel, the proprietor and pharmacist in charge of Newington Pharmacy, 47 Newington Road, Ramsgate, Kent. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Patel had made two dispensing errors during 2002.

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

Mr Patel attended the inquiry and was represented by David Reissner, of Charles Russell (solicitors).

The committee heard that on 26 April 2002 Mr Patel had dispensed a pack of 28 carbamazepine 400mg tablets against a prescription calling for 60 cimetidine 400mg tablets. The patient had not begun to take the erroneously dispensed tablets until just before Christmas of that year. Soon after starting to take them he experienced drowsiness, constipation and confusion. The fact that the wrong tablets had been dispensed came to light when the patient visited his doctor on 13 January 2003. The knowledge that he had taken tablets that had not been prescribed for him had made the patient anxious about his health.

The second error occurred on 7 November 2002 when, in response to a prescription ordering “3 catheters Bard hydrogel coated Aquamatic size 12 CH (male length) PREFILLED 10ml balloon” Mr Patel had dispensed three non-prefilled catheters. As a result, the district nurse who had issued the prescription had been unable to change the catheter of the patient concerned.

The committee was reminded that Mr Patel had previously been reprimanded for dispensing errors in 1998, 1999 and 2001 (PJ, 16 February 2002, p227); further dispensing errors had been established at a hearing in January 2003, when the inquiry had been adjourned as other matters were being investigated.

Long history of errors

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said Mr Patel had a long history of dispensing errors. When announcing the adjournment of the January 2003 hearing, the chairman recalled, he had said that, as Mr Patel had previously been reprimanded, he would almost inevitably have been removed from the register. However, his cramped dispensary, to which some of the problems might have been attributed, had been replaced and a new protocol agreed with the Society’s inspector. This was felt to have reduced the risk of further errors and potential damage to the public.

At the present meeting, however, two further errors had been put before the committee.

Continuing, the chairman said: “We find both these errors established”. While it was true that the first of them had occurred before the premises had been altered and improved, it was a gross and obvious one. It could not have happened if the agreed protocols had been followed through. Regrettably, what marking there had been suggested that a protocol, particularly relating to separate dispensing and checking, had been wholly ignored.

The second error, relating to the supply of the wrong catheter to an elderly man had come after the premises had been improved. Again, it was an obvious and important error. The prescription had stated, in capital letters, “PREFILLED 10ml balloon”. Mr Patel had dispensed catheters which were not prefilled. Those two errors were such as to render Mr Patel unfit to be on the register.

Mr Patel had received repeated reprimands from the committee, which had shown great patience and understanding. However, following “this catalogue of errors over nearly a decade”, said Lord Fraser, the committee did not consider it could be any longer in the public interest that Mr Patel could be reprimanded yet again.

Mr Patel’s name was directed to be removed from the register.

He had three months in which to appeal and was advised that the Council for the Regulation of Healthcare Professionals had authority to intervene in the committee’s proceedings if it wished to do so.

Pharmacist reprimanded after taking medicines for own use

The Statutory Committee has reprimanded a pharmacist who took medicines — mainly codeine linctus — for his own use from the Merseyside pharmacy at which he was employed.

At its meeting on 10 December 2003 the committee inquired into the case of John Robert Campbell, of 13 Carr Road, Hale, Altrincham, Cheshire. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that Mr Campbell had taken medicines (including prescription-only medicines) from his employer without any authority. It was also alleged that he had left, in various places around the pharmacy he managed, medicine bottles that had previously contained codeine linctus, and he had consumed codeine linctus directly from stock bottles on the premises.

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

Mr Campbell represented himself at the inquiry.

The committee heard that between 1994 and 2002, while Mr Campbell had been manager and pharmacist in charge of a pharmacy at 30 Hoylake Road, Bidston, Birkenhead, members of staff had on many occasions found unlabelled medicine bottles in various rooms in the premises. On some occasions they were found to contain a small quantity of liquid, on others they were empty save for a residue; both liquid and residue appeared to be codeine linctus.

Among other incidents, they had also seen codeine phosphate tablets in his briefcase on one occasion, and he had been seen to drink codeine linctus from a stock bottle on several occasions.

Concerned at Mr Campbell’s behaviour, they had reported the matter to the pharmacy’s owners; Mr Campbell had been interviewed by the area manager, suspended immediately, then dismissed.

Interviewed by one of the Society’s inspectors, Mr Campbell had admitted taking codeine linctus and, on occasion, codeine phosphate tablets, over a period of about six years, and that he had never had a prescription. He explained that he had often taken one or two doses a day but that the amount had increased substantially in the latter period of his employment following a change of ownership of the pharmacy. He had accepted that if a member of the public had requested supplies of codeine linctus over a long period he would not have been prepared to make the supply and would have wished the patient’s doctor to be involved.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that the case against Mr Campbell had been established and amounted to conduct such as to render him unfit to be on the register. However, the committee would not make any direction for his removal. The reasons were as follows.

First, Mr Campbell had co-operated with the Royal Pharmaceutical Society throughout its investigations. Second, there was no evidence of any psychological addiction. Third, his behaviour had been, in effect, a misguided effort at self-medication to relieve a life-long medical condition. Fourth, Mr Campbell had been re-employed and had a very supportive set of references. And, finally, since his suspension over a year previously, there appeared to have been no reliance whatsoever by him on codeine linctus.

The Committee reprimanded Mr Campbell.

Reprimand for pharmacist who failed to take appropriate action after patient injected adrenaline that had been dispensed in error

A West Midlands pharmacist has been reprimanded by the Statutory Committee after he had dispensed adrenaline ampoules to an addict instead of methadone. The patient, who had suffered side effects after he injected one of the ampoules intravenously, had not been advised to seek medical attention.

When it met on 9 December 2003, the committee inquired into the case of John David Bryant, of 9 White House Green, Solihull, West Midlands. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that on 11 October 2002, while locum pharmacist in charge of Brights Chemist, 1 Middlemore Road, Northfield, Birmingham, Mr Bryant had dispensed in error three ampoules of 0.5ml adrenaline injection BP 1 in 1000, labelled as methadone, on a prescription calling for three methadone BP ampoules 50mg/ml It was also alleged that Mr Bryant had failed to advise the patient concerned to seek immediate medical advice after he had injected one of the ampoules; that he had failed to advise the patient’s father that his son should seek immediate medical advice; and had failed to contact the patient’s doctor or drug addiction clinic, or the superintendent pharmacist of Brights Chemist.

Geoff Hudson, of Penningtons (solicitors) appeared at the meeting to present to give the facts of the case.

Mr Bryant, who was present at the inquiry, represented himself.

The committee heard that the patient to whom the adrenaline ampoules had been erroneously dispensed was an addict; he had administered one ampoule to himself intravenously shortly after it had been dispensed. Almost immediately, he had felt great pressure in his head, his heart began to race and he had been unable to control his hands. He had returned to pharmacy in a state of distress, told Mr Bryant what had happened and returned the unused ampoules of adrenaline.

Mr Bryant had assured the patient that he would be “all right” so long as he took no other medication for four hours. He did not, however, advise him to seek medical advice. Nor did he contact the addiction clinic that had issued the prescription, the patient’s doctor, the pharmacy manager or superintendent pharmacist. When the patient’s father had visited the pharmacy later the same day, he had not suggested that medical attention should be sought.

The patient himself saw his doctor on 14 October, when his blood pressure and heart rate were found to be very high. He was advised to attend the local hospital accident and emergency unit.

A trainee dispensing technician at the pharmacy had been sufficiently concerned that Mr Bryant had not informed the branch manager that she sent a text message alerting her to the incident and made an entry in the error book.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that Mr Bryant, who had been a pharmacist for “44 distinguished years” had not tried to excuse his error.

The original error had been that the adrenaline ampoules had been put in the Controlled Drugs cabinet and then put in a bag for the patient. Nevertheless, said the chairman, Mr Bryant had not checked what was in the ampoules, only that there were three of them and they were not damaged.

When the patient returned to the pharmacy after having injected one of the ampoules, Mr Bryant had appreciated immediately what had happened. He had then decided, erroneously, after observing the patient and concluding that his symptoms were subsiding, that he should simply advise him to lie down and take none of his other medication.

Mr Bryant had consulted the British National Formulary, where it stated in relation to adrenaline/epinephrine “IMPORTANT. Intravenous route should be used with extreme care”. It was odd, continued Lord Fraser, that having looked that up he had not then advised the patient to seek medical advice.

The dispensing error had been compounded by Mr Bryant’s failure to advise and inform, said the chairman. That amounted to misconduct such as to render him unfit to be on the register. However, Mr Bryant had been open and frank with the committee and had now retired from practice.

The committee reprimanded Mr Bryant.

Restoration decision postponed in case of pharmacist struck off for Viagra offences

The Statutory Committee has postponed its decision on a London man’s application for restoration to the Register of Pharmaceutical Chemists after learning that he had been interviewed in connection with counterfeit Viagra.

At its meeting on 26 January, the committee heard an application for restoration to the register from Rajendra Gulubchand Shah, of 8 Bush Hill Road, Kenton, Harrow, Middlesex. Mr Shah’s name had been ordered to be removed by the committee at a three-day hearing on 26, 27 and 28 February 2002; the removal took effect on 27 May 2002. Mr Shah had sold Viagra without a prescription to a journalist from the Sunday People and had failed to ensure that accurate records of Viagra transactions had been kept (PJ, 7 December 2002, p829).

Geoff Hudson, of Penningtons (solicitors) represented the Society at the hearing.

Mr Shah was present; he was not represented.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said the committee was confident that Mr Shah was “well on his way” to learning his lesson. The evidence he had given indicated that at the pharmacy where he continued to work, the record keeping was up to date, emergency supplies were made only in accordance with the law, and that he would not fall for a ruse such as that played on him by the reporter from the Sunday People.

Lord Fraser said he had used carefully the phrase “well on his way” to learning his lesson. The committee had previously indicated that it would regard two years as being the minimum period before it would consider an application for restoration other than in exceptional circumstances. In this particular case, the incident complained of related to a date in October 1999 and there had been a considerable lapse of time before it came before the committee. In such circumstances, he said, it might seem appropriate to allow the restoration of Mr Shah’s name immediately. However, the committee wanted to make clear that it did not want to see a series of applications coming before it too soon.

It had decided, therefore, to postpone consideration of Mr Shah’s application until the second anniversary of its earlier decision, 27 May 2004. If nothing further came before it in the intervening period, a direction would be made for the restoration of Mr Shah’s name. The hearing was adjourned.

When the hearing of the application was resumed on 21 June, Geoff Hudson, of Penningtons (solicitors) again presented the facts of the case. Mr Shah attended and was represented by David Aaronberg, of counsel, instructed by Turner & Debenhams (solicitors).

The chairman (Lord Fraser of Carmyllie, QC) said that at the January hearing Mr Shah had declared that he had made every effort to work within the boundaries of the law. At that time he had known that he had been interviewed about counterfeit Viagra, in October 2003, and he should have brought that fact to the committee’s attention. This had now been done.

The committee would make no decision now on Mr Shah’s application for restoration but would continue the case for another three months in the hope that it would find out during that period what action it was proposed to be taken.