Statutory Committee

Striking-off order follows string of dispensing errors

A pharmacist is to have his name removed from the Register of Pharmaceutical Chemists on the direction of the Statutory Committee after he was found to have dispensed methadone unlawfully, made a string of dispensing errors and responded inappropriately when one error was drawn to his attention.

The committee took no action against a pharmacy company and its superintendent pharmacist in relation to an allegation of failure to exercise proper control over the pharmacy in which most of the errors occurred.

At its meeting on 21 to 24 August, the committee inquired into a complaint by the Council of the Royal Pharmaceutical Society against Omotayo Enitan Adekaiyaoja (registration number 1062304), Martyn James Hardy (registration number 71137) and Sainsbury’s Supermarkets Ltd, of which company Mr Adekaiyaoja was a former employee and Mr Hardy was superintendent pharmacist.

Misconduct

In relation to Mr Adekaiyaoja, the Council alleged that misconduct such as to render him unfit to have his name on the Register of Pharmaceutical Chemists may have been demonstrated, individually or cumulatively, by the following:

· The supply of methadone mixture to a patient on a date not specified on the prescription and a subsequent intention to supply methadone mixture to the same patient on a date not specified on the prescription

· The supply of 56 thyroxine tablets 25µg labelled as atenolol tablets 50mg in response to a prescription calling for 56 atenolol tablets 50mg

· The supply of 46 Imdur tablets 60mg labelled as diltiazem (Tildiem) 60mg MR tablets in response to a prescription calling for 84 diltiazem hydrochloride MR tablets 60mg

· The supply of 28 Zestril, labelled as ramipril (Tritace) 5mg capsules, in response to a prescription calling for 56 Ramipril capsules 5mg

· The supply of 28 metformin tablets 500mg and an owing note for 56 metformin tablets in response to a prescription calling for 84 metformin hydrochloride tablets 850mg

· The supply of Medisense G2 sensor electrodes labelled as Medisense G2 test strips in response to a prescription calling for 4 x 50 Medisense Soft-sense test strips

· The supply to a patient of a Combivent inhaler that had been prescribed for a different patient

· His signing of the label on a supply of 56 azathioprine tablets 50mg using the initials of the pharmacy manager

· His supply of porcine isophane insulin 30/70 against a faxed prescription calling for “insulin isophane inj 100units/ml”, his poor understanding of diabetes and its treatment, the manner in which he dealt with the error and his insistence that the faxed prescription had called for porcine isophane insulin 30/70 when it had not

With regard to Mr Hardy, the Council alleged that a failure to exercise adequate control over Sainsbury’s North Cheam pharmacy may have demonstrated misconduct such as to render him unfit to have his name on the Register of Pharmaceutical Chemists.

The Council further claimed that the alleged misconduct by Mr Adekaiyaoja and/or Mr Hardy may have been such as to render Sainsbury’s Supermarkets Ltd liable to disqualification.

The committee heard that, apart from the insulin error, all the allegations related to the period between between February and August 2003, when Mr Adekaiyaoja was employed at a Sainsbury’s pharmacy in North Cheam, Surrey.

The insulin error happened on 13 January 2004 when Mr Adekaiyaoja was a locum pharmacist in charge of a Moss pharmacy in King’s Lynn. When the patient’s GP telephoned him about the error, Mr Adekaiyaoja maintained that the faxed prescription had called for porcine isophane insulin 30/70 and told the GP that “it won’t make any difference”. When the patient later returned to the pharmacy, Mr Adekaiyaoja failed to acknowledge the error and invited the patient to look in the pharmacy refrigerator himself to find the correct medicine.

Mr Adekaiyaoja was not present at the inquiry and was not legally represented.

Adequacy of control

In relation to Mr Hardy, the Council alleged that Mr Adekaiyaoja’s errors demonstrated that the Sainsbury’s superintendent pharmacist had not exercised adequate control over the North Cheam pharmacy. The Council also alleged that, when informed that six dispensing errors had occurred at the pharmacy between 26 April and 2 July 2003, he had failed to take adequate steps to prevent further errors occurring. He had also allegedly failed to ensure that working conditions allowed services to be provided to professionally accepted standards, in that Mr Adekaiyaoja had on occasions worked 46 hours or more in a week, including shifts of up to 14 hours.

Mr Hardy told the committee that he might have given Mr Adekaiyaoja too much leeway. He added: “Where we probably went wrong was trying to operate a culture of ‘no blame’ where we encouraged people to tell us about the dispensing errors. We have now changed that.”

Giving the committee’s determination on 26 September. the chairman, Lord Fraser of Carmyllie, QC, said: “To make it clear beyond any peradventure, we shall conclude no further action against Mr Hardy nor against Sainsbury’s. But against Mr Adekaiyaoja there are very different considerations on which we have needed to reflect.”

Noting that Mr Adekaiyaoja had not attended the inquiry or been represented, the chairman said: “That always causes me problems, as I take the stern view that in the event of a non-appearance personally or through a lawyer we must be particularly attentive to the burden on the Royal Pharmaceutical Society to establish its disciplinary case.” The committee had therefore put the Society’s lawyer through the mill.

The chairman said that the committee had sought to deal with the case with fairness and impartiality. If it had inadvertently not explored an avenue that Mr Adekaiyaoja would have wanted it to pursue, it was not through lack of trying.

Serious allegations

The chairman said that the allegations against Mr Adekaiyaoja were serious ones. Although the committee could not confidently conclude that Mr Adekaiyaoja signed a label using someone else’s initials but it did conclude that he made the alleged erroneous supplies and also supplied or intended to supply methadone unlawfully. And it concluded that Mr Adekaiyaoja had demonstrated such misconduct as to render him unfit to have his name on the Register.

The chairman emphasised that the committee had seen no evidence of a systemic failure for which Mr Hardy or Sainsbury’s had to accept responsibility. Both would, however, be well advised to be hawk-eyed in their employment and overview of the likes of Mr Adekaiyaoja in the future.

Turning to the complaint relating to the Moss pharmacy, the chairman said that it was an alarming incident, although he was not sure whether Mr Adekaiyaoja’s observation that “it won’t make a difference” demonstrated “a poor understanding of diabetes and its treatment”. However, his apparently casual invitation to the patient to look in the refrigerator for the right medicine had shocked the pharmacists on the committee.

“All in all,” concluded the chairman, “his conduct is to be regarded as reprehensible and, in our view, his conduct was not only such that he is unfit to be on the Register but we direct that his name should be removed. If there are circumstances in mitigation, which we doubt, none was presented before us, notwithstanding the fact that every opportunity was given to Mr Adekaiyaoja so to do.”

Mr Adekaiyaoja was to be informed that he had a three-month period in which he might lodge an appeal.