Statutory Committee

Pharmacist struck off for driving after taking drugs more

Pharmacist reprimanded for errors on a day of “multiple failings” more

Striking-off after ignoring warnings and advice more

Pharmacist struck off for driving after taking drugs

A Kent pharmacist who was jailed after a second conviction for driving while unfit through drugs is to be removed from the Register of Pharmaceutical Chemists on the order of the Statutory Committee.

On 21 March the committee inquired into the case of Philip John Terry (registration number 72613), of Herne Bay. Information had been received that, on 21 June 2002 at Medway Magistrates’ Court, Mr terry had pleaded guilty and had been convicted of having on 23 March 2002 driven a motor vehicle while unfit to drive through drugs, for which he was fined £300 and ordered to pay Crown prosecution costs of £55, His driving licence was endorsed with nine penalty points.

Later, on 9 September 2004 at Thanet Magistrates’ Court, again following a plea of guilty, he was convicted of having on 26 May 2004, at Ramsgate, driven a motor vehicle while unfit to drive through drugs. He also pleaded gulity to having stolen 94 dihydrocodeine tablets, 15 codeine phosphate tablets and three diazepam tablets. He was sentenced to 28 days’ imprisonment (concurrent) on each charge and ordered to pay Crown prosecution costs of £42. His driving licence was endorsed and he was disqualified from holding a licence for three years.

The Thanet court noted in its opinion that the offence or the combination of offences were so serious that only a sentence of imprisonment could be justified because of Mr Terry’s position of trust and because, as a pharmacist, he knew the effects of unprescribed drug taking.

Mr Terry chose not to appear at the committee’s inquiry and was not represented.

The committee heard that on the first occasion Mr Terry had crashed into a concrete barrier around roadworks. Police officers had seen him weaving between lanes while slumped against the driver’s door pillar. They found that he had slurred speech and he performed badly in a series of ability tests.

He told the officers that he had taken tablets for his epilepsy and four dihydrocodeine for a headache. A blood sample also showed evidence of diazepam.

On the second occasion Mr Terry had crashed into an oncoming car, causing whiplash injuries to the other driver’s neck and shoulder. Police officers found dihydrocodeine, codeine phosphate and diazepam tablets in his pocket.

He claimed that he had taken the tablets from a disposal bin at the pharmacy in which he was working because he had a headache and needed to calm down. But he later claimed he had taken the tablets as an experiment.

Giving the committee’s determination, the chairman, Lord Fraser of Carmyllie, QC, said that the committee found Mr Terry’s convictions established and, having regard to the remarks made when he was sentenced, had no option but to direct that his name should be removed from the Register.

The chairman added that because Mr Terry had not attended the hearing it was difficult, if not impossible, to assess the extent of his drug dependence. If he ever wished to seek restoration to the Register, the committee would want to be satisfied that he had no dependency on any drug and he should be prepared to provide evidence to that effect.

After a three-month period to allow for an appeal, Mr Terry’s name was removed from the Register on 23 June.

Pharmacist reprimanded for errors on a day of “multiple failings”

The Statutory Committee has reprimanded a London pharmacist who, during a single day’s work as a locum, made one dispensing error and two labelling errors, failed to record a supply of a Controlled Drug and failed to refrigerate a delivery of insulin.

At its meeting on 24 March, the committee inquired into a complaint by the Council of the Royal Pharmaceutical Society against Domenico Loiacono (registration number 1078636). The Council alleged that on 7 January 2004, while in charge of a pharmacy in Corringham, Essex:

· He dispensed Fucithalmic eye drops, labelled “Fucithalmic eye drops 30g”, in response to a prescription for “Fusidic acid H/C cream 30g”, and failed to appreciate the difference between the products
· In response to a prescription calling for 56 thyroxine 25mcg tablets, he dispensed 28 thyroxine 25mcg tablets labelled with the name of the patient’s daughter
· In response to a prescription calling for one pack of four Fosamax 70mg tablets, to be taken once weekly, he dispensed the correct pack but labelled it as 28 Fosamax 10mg tablets with a direction that they be taken daily instead of weekly
· After supplying a balance of 30 Sevredol 10mg tablets owed on a prescription for 56 tablets, he failed to make an entry in the CD register, and subsequently failed to give an adequate explanation for his failure
· He failed to check a wholesaler’s delivery that included insulin needing refrigeration Mr Loiacono admitted making a number of errors that amounted to misconduct.

Geoff Hudson, for the Society, told the hearing that Mr Loiacono made the errors on a busy but not stressful day. The “multiple failings”, compounded by a failure to give his employer adequate or truthful explanations, rendered him unfit to remain on the register.

Mr Hudson said that, when confronted over the eye drop error by the pharmacy’s managing director, Mr Lioacono had tried to play it down and had displayed a “worrying failure to appreciate the difference” between the cream and the eye drops. And when asked about the CD register omission, he had said that some pharmacists entered the whole amount when the first supply is made and that there was therefore no need for an entry to be made when the balance was supplied.

But Mr Loiacono told the committee that he had made his comment about the CD register in a panic and he admitted forgetting to make the entry.

On the eye drops error, he said that his apparent failure to appreciate the difference between the products arose from a misundertanding. He had thought the complaint was that he had dispensed plain fucidic acid cream rather than fusidic acic eye drops.

He also told the committee that the labelling errors arose partly from his lack of experience of the pharmacy’s computer system, which he had used only once before.

The committee heard that Mr Loiacono has an otherwise clean record and has regular work in Tesco, Boots and Moss pharmacies.

Giving the committee’s determination, the chairman, Lord Fraser of Carmyllie, QC, said: “Given the admissions before us, we find the dispensing error established, and also the complaint relating to the labelling, the failure to make an entry in the CD register and, as he accepted, even if unaware of the insulin being on the premises, he had the ultimate responsibility for it.” So far as his conversation with the managing director was concerned, the committee concluded that there was simply a misunderstanding and Mr Loiacono had not attempted to make light of the error.

The chairman said: “If these errors had occurred over a protracted period, we would have had some hesitation in concluding that his actions amounted to such misconduct as to render him unfit to be on the register. The deficiencies here all took place in the space of half a day at the most and in these circumstances we do come to the conclusion that they amount to such misconduct as to render him unfit to remain on the register.

“Having said that, we will not make a direction for the removal of his name from the register, for the following reasons: first of all, he has good references; he is restricting his activity to three employers and they have all indicated that they would continue to employ him; furthermore, he has taken on board the good advice he received from [the inspector] and has now changed his dispensing practices.

“In those circumstances we have come to the conclusion … that we can restrict our sanction to a reprimand.”

Striking-off after ignoring warnings and advice

A Dorset pharmacist who let his pharmacy descend into a chaotic state despite warnings, advice and offers of assistance is to be removed from the Register of Pharmaceutical Chemists on the order of the Statutory Committee.

On 22 March, the committee inquired into a complaint by the Council of the Royal Pharmaceutical Society against Brian James Partridge (registration number 64916), who at the material time was sole proprietor of a pharmacy in Winton, Bournemouth. The Council alleged that a catalogue of dispensing errors and unsafe practices individually or cumulatively demonstrated misconduct such as to render Mr Partridge unfit to remain on the Register. In summary the Council’s allegations concerned:

· Patient-returned Controlled Drugs in an open DOOP (destruction of out-of-date products) bin in the dispensary (six instances)
· Date-expired medicines on the dispensary shelves
· Inadequately labelled medicines in the dispensary and a back room
· Mixed brands of loose tablets in one stock container on the dispensary shelves
· CDs (other than patient returns) on the dispensary shelves and in the open DOOP bin
· Incorrectly assembled monitored dosage system trays (three instances)
· Two opened containers of liquid medicines that had not been marked with the date of opening
· Two patient-returned medicines (other than CDs) on the dispensary shelves
· Two unlabelled Nomad monitored dosage system trays containing tablets and/or capsules
· The dispensing of prescription-only medicines (POMs) to patients other than in accordance with a prescription (seven counts)
· Inadequate procedures for preparing monitored dosage system trays
· Supplying POMs in advance of receiving prescriptions
· The absence of final checks before dispensing
· Failing to label dispensed medicines (including some that already bore labels applied in a hospital pharmacy)
· Supplying methadone to a patient’s wife without having obtained the patient’s written authorisation to collect it
· Dispensing sugar-free methadone to a patient whose prescriber had not specified the sugar-free form
· Inappropriate behaviour towards the mother of a young patient whose home he visited to rectify a dispensing error, in that he patted her several times on the buttock
· The poor condition of the dispensary
· Failure to make full records of dispensed private prescriptions
· Failure to allow a locum pharmacist access to the pharmacy to deal with issues outstanding after he abruptly terminated the locum’s employment

Mr Partridge admitted most of the matters of complaint but denied misconduct in relation to the methadone supply to a patient’s wife and the alleged “inappropriate behaviour” towards a patient’s mother.

The committee heard that some of the matters of concern had been raised by a locum pharmacist employed by Mr Partridge to cover his absence for two weeks from 5 January 2004. A Society inspector had then found other matters during an inspection of the pharmacy on 12 January 2004 and during further investigations.

The committee also heard that a number of the matters of concern had previously been the subject of advice by the inspector during visits in 2003. In 1999 the Society had sent Mr Partridge a warning letter about the state of his premises. In addition to advice from the inspector, Mr Partridge had received advice on several occasions from the clinical governance facilitator and the pharmaceutical adviser of Bournemouth Primary Care Trust, following complaints to the PCT.

Giving the committee’s determination, the chairman, Lord Fraser of Carmyllie, QC, said that the notice of inquiry for the case was one of the most elaborate the committee had seen. Mr Partridge had admitted that his actions in the pharmacy amounted to such misconduct as to render him unfit to be on the Register and with two exceptions he admitted all the allegations in the notice of inquiry.

The first of the two exceptions related to his failure to secure a letter of authorisation to allow a patient’s wife to collect his methadone. The chairman said: “We were pointed to a passage in the Fitness to Practise Fact Sheet No 1, last amended in November 2004, at page 11. And it has this to say, ‘However when supply is for treatment of an addict, it is known that many supplies do not reach the intended patients. It is therefore useful to require a letter of authority from the addict before making a supply to his agent. Such documents can assist both the medical profession and the enforcement authorities in the proper management of supplies to addicts.’

“We do not understand that to be an absolute requirement on a pharmacist, but it is nevertheless clearly good practice. We would lay stress on the word ‘useful’, but in all the circumstances we would delete this part of the notice of inquiry and complaint against Mr Partridge.”

On the other allegation to which Mr Partridge took exception, that of “inappropriate behaviour”, the chairman said that the committee would make no finding against him. This was not because it had any cause to disbelieve the complainant but was following a dictum set out in a case that reached the House of Lords that in sexual abuse cases, while the standard of proof remains the balance of probabilities, the balance of probabilities shifts as the allegation becomes more serious. “This allegation of inappropriate patting is a serious allegation and falls just this side of what might be described as an indecent assault,” said the chairman, “but we will make no finding on this for reasons that I have spelt out.”

The chairman said that Mr Partridge had been repeatedly warned and offered assistance from both the Society and the PCT. Notwithstanding those offers, matters had gone from bad to worse. The locum had painted an honest but disturbing picture of the workings of the pharmacy. On the basis of all that was put before it in evidence, the committee would have concluded that Mr Partridge was unfit to be on the Register even if he had not admitted it.

In those circumstances, given the limitations on its present powers, the committee had no option but to give a direction for the removal of his name from the Register. Counsel for Mr Partridge had urged the committee to adjourn for an appropriate period, but the committee was not inclined to follow this course and the case was too serious for a reprimand.

Mr Partridge had three months in which to appeal against the decision. His name was removed from the Register on 23 June.