Statutory Committee

Poor handling of complaint about dispensing error leads to admonition for Lloyds superintendent

Poor handling of a complaint about a dispensing error has resulted in an admonition from the Statutory Committee for the superintendent pharmacist of Lloyds Pharmacy Ltd as well for the pharmacist who made the error.

On 21 November 2005 and 20 and 22 March 2006, the committee inquired into the case of Maria-José Mariscal Navarro (registration number 1078456) and Andrew Murdock (registration number 73499). The committee had received a complaint from the Council of the Royal Pharmaceutical Society alleging that misconduct such as to render Ms Mariscal Navarro unfit to have her name on the Register of Pharmaceutical Chemists may have been demonstrated by a labelling error and/or by her failure to deal appropriately with a subsequent complaint. The Council also alleged that misconduct such as to render Mr Murdock unfit to have his name on the Register may have been demonstrated by his failure as superintendent pharmacist to ensure that Lloyds handled the complaint appropriately.

The committee heard that Ms Mariscal Navarro had at all material times been employed by Lloyds Pharmacy Ltd at its pharmacy at Market Square, Wellington, Telford, Shropshire. The Council alleged that on or about 18 March 2004, in response to a prescription for a seven-year-old child calling for 140ml fluoxetine liquid 20mg/5ml, with a dose of 10mg daily, Ms Mariscal Navarro had dispensed two bottles of 70ml fluoxetine oral solution 20mg/5ml both labelled with the direction “Take two 5ml spoonfuls daily”.

The child’s parents administered the medicine as directed on the label, as a result of which the child received 40mg of fluoxetine daily instead of the prescribed 10mg. By about 23 March 2004, the child’s behaviour had deteriorated to such an extent that his parents consulted his psychiatrist. The error was discovered and the parents were advised to discontinue the fluoxetine immediately.

The Council alleged that, on 24 March 2004, when the error was drawn her attention by the child’s parents, Ms Mariscal Navarro failed to identify that she had made a labelling error and failed to check the accuracy of a statement by a pharmacy assistant, made in front of the parents, that the error had been made by the prescriber. It was also alleged that when the prescriber telephoned the pharmacy about the error, Ms Marischal Navarro told him that the mistake was his.

No contact

The committee also heard that, although the dispensing error was reported to the Lloyds head office by Ms Mariscal Navarro on 24 March 2004 and by the pharmaceutical adviser for Telford and Wrekin Primary Care Trust on 6 April 2004, the company made no contact with the child’s parents until 19 April 2004 and did not send a letter of apology until 27 April 2004.

When the pharmaceutical adviser reported the incident on 6 April 2004 she was told that, despite the error having been reported by Ms Mariscal Navarro two weeks earlier, the company had not contacted the child’s parents and had not investigated the circumstances leading to the error. When she contacted the Lloyds head office again on 13 April 2004 she was advised that action had still not been taken.

On 19 April 2004 the pharmaceutical adviser met the child’s parents, who complained that they had had no communication from the company. Following that meeting, she again contacted the head office and was advised that the error had been referred to the company’s new area manager. The area manager then telephoned the parents to discuss the error and arranged a meeting with them on 22 April 2004, when she apologised for the “inexcusable” delay in contacting them.

On 27 April 2004, the pharmaceutical adviser was told by the parents that they had still received no letter from Lloyds and intended to bring the matter to the attention of the news media. Following another telephone call by her to the Lloyds head office, the company’s deputy superintendent pharmacist spoke to the child’s parents on the same day and sent a letter apologising for “the inordinate delay in our response to this incident”.

Admitted labelling error

Giving the committee’s determination, the chairman, Lord Fraser of Carmyllie, QC, said that the complaint fell into two parts. The first was a complaint against Ms Mariscal Navarro. There was an admitted labelling error on her part, although the form of the prescription may have been less than clear or stated by the prescriber in unusual terms.

The chairman continued: “As the professional disciplinary body we can only regard the error as reprehensible. The pharmacist had two options: get it right or, if uncertain, contact the prescriber to ascertain what was being lawfully prescribed. Regrettably, Ms Mariscal Navarro got it wrong and she did not contact the prescriber. This is admitted by her and we can only conclude that there was indeed a labelling error on her part.”

The chairman continued: “The Statutory Committee, so long as it exists, must respond to the greater responsibility that Parliament and society requires of pharmacists. The Scottish Executive is giving greater prominence to the role of pharmacists in Scotland and we detect nothing elsewhere in Great Britain which does anything other than elevate the status of pharmacists, but what pharmacists must recognise is that as their professional status in society is increasingly relied upon, along with that goes a greater responsibility from which the Statutory Committee will not allow them to shrink.

The chairman added that more difficult was the alleged failure “to deal with the complaint appropriately”. The committee was uncomfortable with that and could not conclude properly that Ms Mariscal Navarro failed to deal appropriately with the complaint.

“In the circumstances we can do no more than slap her wrists. The Statutory Committee would regard her failing in the circumstances of a relatively obscure prescription to warrant no more than an admonition, and that is our conclusion in the case against her.”

Response to complaint

Turning to Mr Murdock, the chairman said that Lloyds had no direct responsibility for the error. The issue was how it responded to the complaint. Mr Murdock had been commendably frank, and the committee would suggest that superintendent pharmacists of comparable major chains should emulate his honesty and integrity. But there was no doubt that the parents of the autistic child should have been contacted more quickly and more sympathetically than was done.

“ Mr Murdock cited chapter after chapter of circumstance that militated against a swift handling of the complaint. This ranged from the unexpected departure of a member of staff, the extended bereavement leave of another and a third who has moved and who has subsequently failed to respond to queries. Mr Murdock had a problem on his hands and the complaint was not swiftly handled. To be fair, we accept that subsequent to this unhappy episode Lloyds has conducted the most thorough review of its internal procedures and that remains ongoing.”

Nevertheless, said the chairman, the committee was bound to conclude that Mr Murdock, as superintendent pharmacist, allowed his conduct to fall short of what the public should expect. To his credit, he was not proud of the company’s inadequate response and had instigated a thorough review of procedures. For that, the committee respected him. But, in the public interest, it would not do for Mr Murdock simply to claim internal problems. His company failed to deal properly with the valid complaint. Its internal procedures were mechanistic and inflexible.

Mr Murdock should reflect carefully on where the public interest lies, the chairman suggested. With that stricture, the committee would also “slap him on the wrists, albeit even more lightly than Ms Navarro, and conclude the case against him with an admonition”.