No penalty for dispensing medicines wrongly ordered by GP surgery
The Statutory Committee has decided to take no action against a locum
pharmacist who supplied a patient with the wrong medicines on the authority
of an erroneous telephone call from a GP surgery. The committee ruled
that a pharmacy company and its superintendent pharmacist, who were
party to the inquiry, had no case to answer.
The case, which opened on 20 October and concluded on 21 November, concerned
Peter Chung Lan Chiu (registration number 78926), Anchor Health Ltd and
Ajay Kant Dharampal Walia (registration number 76620).
The case arose from a complaint by the Council of the Council of the
Royal Pharmaceutical Society, which alleged that misconduct such as to
render Mr Chiu unfit to have his name on the Register of Pharmaceutical
Chemists may have been demonstrated, individually or cumulatively, by:
· Supplying prescription-only medicines without the authority of a prescription
in circumstances where the conditions for a lawful emergency supply were
not satisfied
· Supplying POMs that the patient’s GP had not intended her to
receive, without making enquiries of the prescriber when it was apparent
that the medicines were different from those the patient normally received
The Council also alleged that misconduct such as to render Mr Walia
unfit to be on the Register and the company liable to disqualification
may have been demonstrated, individually or cumulatively, by the above
and by a failure to introduce procedures to minimise risks and to handle
complaints.
The committee heard that since about 2000 Mr Chiu had from time to time
been employed as a locum pharmacist by Anchor Health Ltd at Currans Pharmacy,
London W9, and was pharmacist in charge at the material time because
Mr Walia was away on holiday.
The patient concerned was a frail 86-year-old woman who had just been
discharged from hospital. On 1 April 2004 her GP had generated a prescription
for several medicines. The prescription was not passed to the patient
or sent to the pharmacy. Instead, a member of the surgery staff telephoned
the pharmacy, but what she read out was a prescription for several medicines
for a different patient who was not known at the pharmacy.
In a subsequent telephone call, Mr Chiu was told that the medication
was being changed and that the prescription was urgent. He twice sent
a driver to collect the prescription but on both occasions the surgery
was closed. Furthermore, the surgery’s fax machine was not working
at the time.
On the next day, notwithstanding the absence of a prescription, a monitored
dosage system (MDS) tray was made up. Having been told that the medication
was to be changed, Mr Chiu was not put on alert by the fact that the
medicines ordered did not coincide with the patient’s medication
record. The medicines were supplied to the patient by the pharmacy driver
on the following morning.
The committee was also told that, in an interview on 6 May 2004, Mr Walia
admitted that he sometimes supplied medicines in MDS trays before receiving
a valid prescription and that his MDS dispensing process had not included
checking the medicines against the prescription. He said that it was
usual practice to take details of POMs over the telephone from the surgery
provided the prescription was “covered by fax or some other document”.
Mr Walia admitted that no standard operatin procedures had been written
for any part of the dispensing process, that the error had not been recorded,
that the pharmacy had no written complaints procedures and that the pharmacy
had no “near miss” log.
Giving the committee’s determination on 21 November, the chairman,
Lord Fraser of Carmyllie, QC, said: “Mr Chiu admits it was misconduct
on his part, but it was submitted on his behalf that it was not such
misconduct as render him unfit to be on the Register. We agree with that.
Mr Chiu should not have supplied medication without sight of a valid
present, but, as I have narrated, he tried to get hold of it twice. He
had been told it was urgent and he may have had two conversations with
the surgery, one possibly with the prescriber herself. He had some reason
to believe it was urgent because a change was being made in the medication
regimen.”
Against that background, the committee was not prepared to conclude that
Mr Chiu’s name should be removed from the Register. So far as Mr
Chiu was concerned, it would take no further action.
Turning to the company and its superintendent, the chairman said the
pharmacy had no audit trail, no SOPs, no error log, no near miss log
and no effective complaint handling procedures. However, not all of these
had been required by the Society at the time of the incident. And even
if such procedures had been in place, they would not have stopped Mr
Chiu acting as he did. In summary, neither Mr Walia nor his company had
a case to answer.
Barrister Jeffrey Jupp said that the case had cost “an awful lot
of money” on the part of Mr Chiu and his insurers. He asked for
Mr Chiu’s costs to be paid by the Society, if the committee had
the power to make such an order.
The chairman replied that the committee had no power to make any order
for the award of costs or even to entertain such an application.
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