Statutory Committee

Admonition follows failure to deal appropriately with dispensing error

A pharmacist who dispensed the wrong product and failed to deal with the error appropriately has been admonished by the Statutory Committee.

At an inquiry held on 15 December 2005 and 23 March, the committee inquired into a complaint by the Council of the Royal Pharmaceutical Society against John Joseph George Barnes (registration number 62087), of Horsham, West Sussex. The Council alleged that misconduct such as to render Mr Barnes unfit to have his name on the Register of Pharmaceutical Chemists may have been demonstrated, individually or cumulatively, by:

· His error in dispensing Picolax sachets, labeled as such, against a prescription for Migramax sachets

· His failure to contact the prescriber to ensure that what was being called for was clear and unequivocal

· His dismissive response to the patient when the error came to light

· His failure to keep an accurate record of what was dispensed in the patient medication record

· His failure to establish how much Picolax the patient had taken and any symptoms suffered

· His failure to inform the patient’s GP that she had taken an incorrect medicine

· His failure to record the dispensing error

The committee heard that the error occurred on 6 July 2004, when Mr Barnes was in charge of a pharmacy in Crawley, West Sussex. On the same day, the patient suffered stomach cramps and diarrhoea after taking a dose of Picolax. On reading the patient information leaflet, she realised she had been given the wrong medicine and telephoned the pharmacy. When she returned to the pharmacy two days later, Mr Barnes allegedly said in a dismissive manner: “It was only a strong laxative”.

Allegations admitted

The committee heard that Mr Barnes had admitted all but the third and fourth of the seven allegations.

Giving the committee’s determination on 23 December 2005, the chairman, Lord Fraser of Carmyllie, QC, said that the committee would make no finding in respect of the final allegation, being uncomfortable with Mr Barnes’s admission of it. But the committee had no real option but to accept the other admissions, even though some did not quite square with Mr Barnes’s own account of events. For example, he had admitted failing to contact the prescriber “to ensure that what was being called for was clear and unequivocal” even though he had stated that there was nothing unclear or unequivocal about the prescription and that he had shown it to the patient so that she could see that it was for Picolax.

It was a matter of misfortune, the chairman said, that the prescription had been lost or destroyed, either in the pharmacy or at the Prescribing Pricing Authority. “This is unsatisfactory for us, as it would have been helpful to have been able to determine for ourselves whether the writing on the prescription was so obscure that such an error as this was more or less inevitable.”

Another unsatisfactory feature of the case was that evidence put before the committee included two copies of a letter from Mr Barnes’s employer, identical except that the words “despite his disability” had been removed from one if them. The committee took exception to any reference being tampered with.

The case would be adjourned for three months to find out what the disability was and whether it might have a bearing on the committee’s decision.

When the inquiry resumed on 23 March, the solicitor acting for Mr Barnes admitted taking it upon himself to delete the words from the reference because there was no suggestion that his client’s medical condition affected his ability to practise or led to the error.

The chairman said that the committee was happy to conclude the case with an admonition provided that Mr Barnes gave a written promise to stop work if his illness worsened to the extent that he was not fit to practise.