Statutory Committee

Dispensing error pharmacist is reprimanded after agreeing to retire more

Poor practice leads to reprimands for pharmacy owner and his locum more

Dispensing error pharmacist is reprimanded after agreeing to retire

A pharmacist who failed to follow Royal Pharmaceutical Society recommendations for minimising the risk of dispensing errors and then failed to take appropriate steps when an error was discovered has been reprimanded by the Statutory Committee after giving an undertaking that he would retire immediately from the practising register.

On 20 April, the committee inquired into a complaint by the Society’s Council against Joseph Karl Francois (registration number 61723) and the company D. H. Roberts (Kentish Town) Ltd, of which Mr Francois was superintendent pharmacist, a shareholder and a director. The Council alleged that the dispensing of 50mcg thyroxine tablets instead of 25mcg tablets, particularly after Mr Francois had accepted the recommendations for minimising the risk of dispensing errors, together with his failure to take appropriate steps when the error was discovered, may amount to misconduct.

The committee heard that on 10 April 2004, at a pharmacy then owned by the company at 165 Fortess Road, London NW5, Mr Francois received a prescription for 336 thyroxine 25mcg tablets with the direction “take six daily”. He dispensed 12 manufacturer’s cartons of 28 thyroxine 50mcg tablets, labelled “28 Thyroxine tabs 25mcg” with the direction “take six daily”. For two weeks, the patient took six tablets daily, thus receiving twice the dose on which he had been stabilised. During that period he felt tired and debilitated.

On 24 April 2004, after spotting the error, the patient went back to see Mr Francois, who failed to apologise, failed to contact the patient’s GP and failed to ask whether thepatient had been taking the drug at twice the correct strength. Mr Francois made no further contact with the patient after his visit and made no written record of the error.

After leaving the pharmacy, the patient consulted an on-call doctor at his GP’s practice and was advised to attend for a thyroid function test. The results were compatible with thyrotoxicosis. The patient continued to suffer adverse symptoms until about mid-May 2004.

The committee heard that Mr Francois was unable to explain his failure to follow the Society’s recommendations, which he had accepted in in 2002. The recommendations had been contained in a letter from the Society’s then head of professional after a previous dispensing error.

The committee was told that the company had sold its pharmacy in October 2004 and was now dormant. Mr Francois was working half a day a week and intended to retire from practice.

Giving the committee’s determination, the chairman, Lord Fraser of Carmyllie, QC, said that the error could have been serious. It had been made against the background of an earlier warning from the Society and would not have occurred if Mr Francois had followed the advice given in that warning.

In the committee’s view, the misconduct was such as to render Mr Francois unfit to be on the Register. However, having regard to his undertakings to relinquish his practising certificate and never reapply to practise, the committee would restrict its sanction to that of a reprimand.

The chairman said: “Mr Francois is now 70 years of age. He has sold his pharmacy. In any event, the amount of practice he is undertaking is limited and he has indicated to us he would not want to renew in 2006. … It would seem to the committee that the course that he now proposes to follow is an appropriate one in all the circumstances.”

The chairman added that the committee would not take exception to Mr Francois registering as a non-practising pharmacist.

Noting that D. H. Roberts (Kentish Town) Ltd was to be wound up once its final accounts had been completed in July, the chairman said that the committee would make no further order against the company.

Poor practice leads to reprimands for pharmacy owner and his locum

A Chester pharmacy’s dispensing of an unlabelled, out-of-date medicine without an accompanying patient information leaflet (PIL) despite repeated advice and warnings has led to reprimands for two pharmacists.

On 20 April, the Statutory Committee inquired into a complaint by the Council of the Society against Robert Mark Nicholson (registration number 70435) and Pak Kao Ho (registration number 74861). The Council alleged that dispensing Premique Cycle tablets that were out-of-date, unlabelled and unaccompanied by a PIL, in circumstances where Mr Nicholson and Mr Ho had received repeated advice and a warning from the Society regarding the requirement to check for and remove date-expired stock from the dispensary and Mr Nicholson had received a warning from the Society regarding the dispensing of unlabelled medication, may amount to misconduct.

The committee heard that Mr Nicholson was a self-employed locum who from about 1998 had regularly worked at Royal House Pharmacy, 12 Upper Northgate Street, Chester. At all material times the pharmacy had belonged to Mr Ho.

On 13 January 2004, while Mr Nicholson was pharmacist in charge of the pharmacy, he dispensed a prescription for 84 Premique Cycle tablets. He supplied three blister strips of 28. They were not in a manufacturer’s outer pack, they were not labelled and he did not supply a patient information leaflet. The strips all bore an expiry date of December 2003.

The patient took one tablet daily for nearly two months, but on 21 March 2004 she noticed that they were out of date. Concerned for her health, she brought the matter to the attention of her GP and was given a new prescription for the following month.

The committee heard that in August 1998, October 1999, March 2000, July 2000, September 2000 and October 2000 the Society’s inspector for the area had spoken to Mr Nicholson about the need to remove date-expired stock from dispensary shelves. And in August 1998, October 1999 and May 2003 he had left advice notes at the pharmacy relating to the same effect. In November 1999 Mr Nicholson had received a warning from the Society following a dispensing of Nuvelle Continuous tablets without a dispensing label. In September 2000, Mr Ho had received a warning from the Society following the dispensing of Becotide Rotacaps that had an expiry date more than one year old the discovery of a significant quantity of other date-expired stock in the pharmacy.

Giving the committee’s determination, the chairman, Lord Fraser of Carmyllie, QC, as that the complaint concerned a single incident for which both men had accepted responsibility and both had apologised. If there had just been a single error it would have been questionable whether it amounted to such misconduct as to render one or both of them unfit to be on the Register. However, there was a context to it. Between 1998 and 2003 the Society’s inspector had repeatedly advised the pharmacy of the need to remove date-expired stock from the dispensary shelves. Furthermore, Mr Nicholson and Mr Ho had each received a warning from the Society.

“ All this colours our view of this single incident,” said the chairman, “and it sets a context within which to consider it. On the basis of the admitted and accepted facts, we consider both Mr Nicholson and Mr Ho are guilty of such misconduct as to render them unfit to be on the Register. We then have to pass to consider whether we will give a direction that their names be removed. On this occasion, we will not give such a direction. While Mr Nicholson continues to work in the same pharmacy, it has been sold by Mr Ho who has no continuing connection with it. The evidence is that all the deficiencies [the inspector] had repeatedly noted over the years and advised upon have been remedied and the situation is much better. Mr Ho no longer owns any pharmacy and he has indicated to us both in his statement and in oral evidence that he has no intention of acquiring one. … In these circumstances, we consider we can restrict our sanction in the case of each of them to that of a reprimand.”