Statutory Committee

Reprimand follows 20-fold dosage error

Alan Woodcock

Alan Woodcock, MRPharmS, of Southport, who is secretary of Sefton Local Pharmaceutical Committee, has asked us to make clear that he is in no way associated with the pharmacy company named Alan Woodcock that was a party to the Statutory Committee inquiry reported on this page.

A Surrey pharmacist who made a dispensing error that resulted in an 80-year-old patient with Parkinson’s disease taking 20 times the prescribed dose of pergolide has been reprimanded by the Statutory Committee. The company took no action against a pharmacy company and another pharmacist who were party to the case.

On 26 April and 26 June, the committee inquired into a complaint by the Council of the Royal Pharmaceutical Society against Richard Gregory Woodroffe (registration number 68919), of Leatherhead, Surrey, Margaret Mary Rita Gorman (registration number 67793), of Redhill, Surrey, and the company Alan Woodcock (company identification number 1001329).

The Council had alleged that a dispensing error in which 1mg pergolide tablets were dispensed instead of 50µg tablets may amount to such misconduct as to render Mr Woodroffe unfit to have his name on the Register of Pharmaceutical Chemists and the company liable to disqualification from owning pharmacies. The Council also alleged that the dispensing error combined with a failure to intervene adequately when alerted to the act that the tablets were of a different colour to the patient’s normal tablets may demonstrate that Mrs Gorman had been guilty of such misconduct as to render her unfit to have her name on the Register.

The committee heard that since 1996 Mr Woodroffe had been superintendent pharmacist and a director of Alan Woodcock, an unlimited company, which was the proprietor of a pharmacy (trading under the same name) in Dorking, Surrey.

On 27 January 2004, when Mr Woodroffe was in charge of the pharmacy, he received a prescription calling for 200 pergolide tablets 50µg with the direction that four tablets were to be taken three times a day. He generated two dispensing labels but could not dispense the pergolide because he did not have it in stock. He intended that the product should be ordered that day from the company’s wholesaler, but the order placed with the wholesalers was for Celance, a proprietary brand of pergolide, at a strength of 1mg (1,000µg) rather than 50µg.

When the Celance arrived from the wholesaler, the labels Mr Woodroffe had generated were fixed by a non-pharmacist assistant to two boxes of 100 Celance 1mg tablets. Mr Woodroffe checked the boxes but failed to note that the wrong strength had been selected.

On 29 January 2004, when Mrs Gorman, an employee of the company, was in charge of the pharmacy, the patient’s wife collected the two boxes of tablets.

Within the next day or two, the patient’s wife noticed that the tablets were pink. She telephoned the pharmacy and asked Mrs Gorman why they were not the usual white colour. Mrs Gorman assured her that she had been supplied with the correct tablets and said that the change of colour was because the tablets were from a different manufacturer with different packaging.

Relying on that assurance, the patient’s wife gave her husband four of the 1mg tablets three times a day until 6 February 2004, when he was admitted to hospital. Hospital staff identified the error and notified Mr Woodroffe.

At a subsequent interview with one of the Society’s inspectors, Mr Woodroffe accepted full responsibility for the error. Also interviewed, Mrs Gorman confirmed that she had had a telephone conversation with the patient’s wife in January 2004 but said that she had not considered that she was being alerted to the possibility of a serious dosage error.

Giving the committee’s determination on 26 July, the chairman, Lord Fraser of Carmyllie, QC, said that with regard to Mrs Gorman the committee’s unequivocal conclusion was that no further action should be taken. The only sustainable complaint against her was that she was apparently dismissive of a complaint against Mr Woodroffe. However, in giving evidence the patient’s wife had insisted that she had spoken to a man. So the committee was confronted with irreconcilable evidence and it would be unsafe to find any case established against Mrs Gorman.

The chairman went on to say that the committee did not much like the complaint against the company either. He explained that to take action against a pharmacy company was only “to put gold into the mouths of lawyers”. That was because it is not difficult, the next day, for the pharmacist in question to approach a lawyer and secure another limited company “off the shelf”. There would be no further action against the company.

Mr Woodroffe was in a different position. He had been open in admitting that he made the dispensing error. He could not explain how he had come to make the error and had sought to apologise by letter. Sadly, the patient had died after his admission to hospital, but it was not contended that there was any direct causal link between the dispensing error and his death. Nevertheless, the committee concluded that the error did amount to such misconduct as to render Mr Woodroffe unfit to be on the Register. It was, however, a single error in some 30 years of practice and the committee would restrict its sanction to that of a reprimand.