Statutory Committee

Reprimand for pharmacist who failed to act appropriately after errors

The Statutory Committee has reprimanded a Cheshire pharmacist who, having wrongly dispensed methadone mixture instead of Oramorph for a young child, replaced the methadone with twice the prescribed quantity of Oramorph. He also failed to take appropriate action after learning that the child had taken a dose of the methadone.

During the course of delivering the committee’s determination, the chairman, Lord Fraser of Carmyllie, QC, criticised the prescriber for not indicating on the prescription that the patient was aged under 12 years, as was required by law, and for expressing the quantity required in a potentially confusing way.

The inquiry, held on 25 April, arose from a complaint from the Council of the Royal Pharmaceutical Society against Mark Derek Robinson (registration number 75404). The Council alleged that misconduct such as to render Mr Robinson unfit to have his name on the Register of Pharmaceutical Chemists may have been demonstrated by:

· His supply of 50ml methadone mixture 1mg/1ml labelled as 50ml Oramorph 10mg/5ml against a prescription requiring 25ml Oramorph 10mg/5ml

· His subsequent supply of 50ml Oramorph 10mg/5ml against the same prescription

· His failure to contact the prescriber and/or to advise the child’s parents to contact the prescriber and/or to give the parents appropriate advice following his discovery of the first dispensing error

· A similar failure following his discovery of the second dispensing error

· His return to a stock bottle of the unused methadone, knowing that the patient had consumed a dose

· His failure to record the supply of the methadone in a Controlled Drugs register

The committee heard that the dispensing errors took place on 29 November 2004, at a pharmacy owned by Mr Robinson in Wilmslow, Cheshire. He received a prescription for “Oramorph 10mg/5ml (Ten milligrams in 5 millilitres) 2.5ml as required up to every 4 hours. Mitte 50mg (50 milligrams)” but supplied 50ml of methadone mixture 1mg/ml labelled as 50ml Oramorph 10mg/5ml with the directions: “Give 2.5ml spoonful up to four hourly”. Having returned home with the medicines, the child’s mother administered a 2.5ml dose. Shortly afterwards, the father received a telephone call from Mr Robinson to say that he had given the wrong dosage and wished to change it. He did not ask whether any medicine had been administered or give any advice or instructions.

About half an hour later, he visited the patient’s home. He told the mother he had given the wrong dosage. When she said she had already given the child a dose of the medicine, he gave no advice or instructions but took the methadone from her and handed her a bottle containing 50ml of Oramorph 10mg/5ml.

During the rest of that day and for the greater part of the following day, the child vomited repeatedly, as a result of which his parents were unable to administer to him the other medicines he had been prescribed.

On 28 January 2005 the child’s mother spoke to Mr Robinson and asked what medicine had been dispensed. Mr Robinson confirmed that he had supplied methadone. When she told him how ill her son had been, he gave no explanation or apology. Later, on an unknown date, he telephoned the father and apologised for the error.

At subsequent interviews with a Society inspector, Mr Robinson admitted the alleged errors and failures to respond appropriately.

Mr Robinson told the committee that at the relevant time he was under serious business pressure. He had now sold his two businesses and was working as a locum. He had no intention of owning a pharmacy again.

Giving the committee’s determination, the chairman said that Mr Robinson had disputed none of the allegations and the committee was satisfied that he had made the two errors and failed in his responsibilities, as alleged. He should not have returned the methadone to the stock bottle but should have disposed of it and he should have made the appropriate entry in the CD register.

“We have little hesitation,” said the chairman, “in concluding that he has been guilty of such misconduct as to render him unfit to be on the Register. There were serious dispensing errors by Mr Robinson, the first the more so, and even if the prescription was not properly completed by this prescriber to give the age and date of birth of the person for which the medicines were being prescribed, Mr Robinson should earlier have taken steps to ascertain that this was a sick child to whom he was dispensing.”

The chairman noted that Mr Robinson, who had registered with the Society in 1982, otherwise had an unblemished record. It was also to his credit that he had been open and frank with the inspector and the committee.

Mr Robinson also had a good set of references, even if they were not in quite the form the committee preferred. It was not 100 per cent clear that all the referees knew exactly what it was that had brought him before the committee.

In all the circumstances, said the chairman, the committee would draw back from directing the removal of Mr Robinson’s name from the Register and restrict itself to a reprimand. He added: “We believe him when he says he has no intention of owning a pharmacy business in the future, and we certainly would not advise him to take up his own business again.

“We have some concern over his self-confidence, but with this hearing behind him, we are confident that it will be restored.”

The chairman added that two general points emerged from the case. The first was that the prescription did not bear the patient’s age or date of birth, although provision was made for this on the face of the prescription. He said: “I wish to emphasise that this is not just a desirable feature of a prescription. It is a legal requirement that where the child is under 12, the age must be stated on the prescription. Both the medical profession and pharmacists should be aware of this legal requirement.”

The second general point was that the second error was occasioned by the prescription being written in a form that would be immediately understood by a hospital pharmacist but was much less common in community pharmacy. He said: “This is not the first occasion where we have encountered an error being caused in this way. The community pharmacist should, of course, be put on alert when the prescription comes in a form with which he or she is not immediately familiar, but a measure of standardisation would seem to us to be desirable to avoid this difference of approach between those who work in the community and those who work in hospitals.”