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Pharmacy investigation after patient death.

The actions of high street chemist, Boots, are being investigated by the General Pharmaceutical Council after the death of a great-grandfather who was sent duplicate packs of prescription drugs.

The man, Richard "Tony" Lee, took a week of extra pills dispensed in error shortly before his death in December 2016.

The General Pharmaceutical Council, which regulates pharmacies, is investigating after a complaint from Mr Lee’s his daughter, Gail Pickles.

Mr Lee, 84, from Doncaster, was supposed to be sent four, 108-pill, weekly packs each month to control heart, kidney and anxiety conditions but after his death, Gail Pickles, found double the expected number of packs, along with evidence he had taken the double dose.

After reporting the duplicated medication packs found among her late father's belongings, she said she was promised there would be an investigation and "Boots would be transparent.”

But, when trying to follow this up in February 2017, she was told the Nottingham-based company "could not comment at this time". Mrs Pickles said the "tone of the letter was shocking.”

At the inquest at Doncaster Coroner's Court, it was revealed that when responsibility for sending the prescription was moved to a new pharmacy, the original pharmacy did not get a message to cancel its order, resulting in two sets of the same prescription being sent to Mr Lee.

Assistant coroner, Louise Slater, said excess dosing would have increased the risk of a cardiac event and was a contributory factor in Mr Lee’s death.

Mrs Slater told the inquest communication problems had resulted in a lack of clarity as to which pharmacy would assume responsibility.

She added "I'm satisfied that policies and procedures were in place at the pharmacies. However, they were not followed on this occasion due an individual failing rather than a systemic failure."

Immediately after the inquest, Mrs Pickles said she was appalled by Boots' actions, particularly the revelation that an internal investigation report into the error stated Mr Lee did not need medical attention and the incident did not need to be escalated.

Mrs Pickles from Penistone, South Yorkshire, also believes the pharmacies had repeatedly failed to meet Boots' own standard operating procedures for dispensing prescriptions.

Boots said it had apologised for the tone of the letter but denied it was not transparent, saying it was unable to comment further while inquest proceedings were continuing.

The company said that it had also repeatedly expressed its condolences about Mr Lee's death, accepts it should have provided a written apology sooner and has offered to meet Mrs Pickles.

The firm insisted "rare and exceptional" circumstances led to the original mistake and it had an extremely low error rate.

Procedures had been updated and pharmacists were asked for feedback about them in 2016 to identify whether any additional support was needed.

Boots accepted there were some failings complying with standard operating procedures in this case but said they were not symptomatic of a wider problem.

The company said that it had fully complied with the coroner's investigation.

The General Pharmaceutical Council said it was investigating Mrs Pickles' concerns and it took all complaints raised extremely seriously - in particular those relating to a patient death.

Mrs Pickles said: "My family were very, very wrong to place our trust in that company. If I hadn't looked through dad's medication and had just taken them back to the pharmacy none of this would have come to light."

 

 

 

 

 

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