THE daughter of a woman who died after being given the wrong medication says proposals to protect pharmacists from prosecution when making such errors are ‘ridiculous’, and could result in more fatal cases like that of her mother.
Mother-of-three Dawn Britton fell into a coma and later died after a locum pharmacist dispensed her tablets for diabetes sufferers, rather than her regular medication that she took to treat Crohn’s Disease.
The 62-year old collapsed after taking the pills, which were a similar shape and size to her regular tablets, with an inquest last October concluding she had died from hypoxia (a lack of oxygen), caused by hypoglycaemia (low blood sugar), as a result of a mistakenly being given a supply of gliclazide tablets as a non-diabetic patient.
Mrs Briton’s children, Tammy Haskins and Lee Britton, were left devastated however when they were told nobody would face a criminal investigation, with prosecutors deciding it would not be in the public interest.
Now, under plans to change the 1968 Medicines Act, no questions may be asked over possible prosecutions in future similar cases, as it is proposed that ‘inadvertent dispensing errors’ be free from any criminal liability.
The plans appear in the ‘Rebalancing Medicines Legislation and Pharmacy Regulation’ document, for which a consultation period recently ended.
At present, dispensing errors are considered “strict liability” offences, which means errors can be classed as a criminal offence, even if unintentional.
Health officials say the proposals are ‘designed to contribute to openness and increased reporting of inadvertent dispensing errors so that everyone can learn from mistakes’.
However, Mrs Haskins fears removing the threat of criminal action completely will only lead to slacker procedures across the board, and more tragic cases of families losing loved ones from similar errors.
“These new proposals aim to take away the fear pharmacists have of being prosecuted, thus reducing the number of errors made, but this is a ridiculous argument,” said Mrs Haskins, who along with her brother is now launching civil claims against both Jhoots Pharmacy in Bristol, and the locum pharmacist who dispensed the wrong drugs to their mother.
“Pharmacists have a duty of care to patients and are highly paid to reflect that responsibility. Surely if there are no sanctions, then procedures will become slacker.
“Any changes should be made to further safeguard patients, not to protect those providing the medication.
“When my mum died after being given diabetic medication in error, I was horrified to find it wasn’t the first reported case. This error proved fatal for my mum, I couldn’t believe it had happened before and measures had not been in place to stop it happening again.
“Steps should have been put into place well before now to prevent this potentially serious error from reoccurring. The impact this error has had on me and my family will never leave us, we have to cope with it every single day.
“In my opinion the law as it stands is very loose anyway. In my mum’s case the CPS decided it was not in public interest to prosecute the pharmacist, even though there was a dispensing and labelling error.”
Renu Daly, a medical negligence specialist at Neil Hudgell Solicitors, believes the proposed changes will do little to improve practices across the board and says regulation needs tightening, particularly given there is no legal requirement for locum pharmacists to follow the operating practices of the pharmacies they operate from.
In the case of Mrs Britton, the locum had been left running the Bristol pharmacy alone for the first time, and admitted during the inquest into Mrs Britton’s death that she had worked hastily and felt pressured running the dispensing counter alone.
“Mrs Britton’s case is a perfect example of why more scrutiny needs to be placed on the procedures within the pharmaceutical industry, not a relaxation of rules,” she said.
“Her family have as yet seen nobody held responsible for the fatal error made that day, and now they are left in the middle, with neither party seemingly willing to take responsibility at all.
“Such a situation leaves people effectively unregulated, and whilst I appreciate the intention behind the new proposals, little in them will ensure such errors are prevented in the first place going forward.
Miss Daly believes both the pharmacy and the locum are jointly liable, given the pharmacy failed to ensure it was sufficiently staffed or had sufficient procedures in place to prevent errors, whilst the locum failed to dispense the drugs correctly, ensure a proper checking procedure was followed or fully focus on the job in hand, having admitted at the inquest that she felt pressurised and worked in haste.
“These proposals appear more focussed on changing the aftermath of such errors and they will only protect the individual pharmacist. They will have a very a limited impact on the protection of the public or on ensuring the safe supply of medication is better regulated,” added Miss Daly.
“Although pharmacy professionals may currently fear criminal sanction as a result of a dispensing error, a relaxation of these rules will do little to reassure the public that there are adequate safeguards in place to ensure the provision of their care."
The new proposals also suggest some patients may not be informed of an error in dispensation at all if thought to ‘trivial’, whilst it is also suggested that any suspicions of errors should not be communicated to patients until an investigation has confirmed the dispensing mistake has in fact been made.
Both of these proposals have angered Mrs Haskins.
“To suggest patients not be told of errors the pharmacy considers ‘trivial’ is outrageous. Where is the openness and transparency they talk about creating there?” she said.
“A patient could become seriously ill from taking wrong medication whilst a pharmacy delays in being honest and frank about their concerns in order to investigate their suspicions. There may not be time to carry out these checks.
“If people were given a choice of either knowing or not knowing that an error may have been made, I am confident most people would want to know.
“There needs to be a standardising of operating procedures in which it is made compulsory to have two people checking medication before dispensing. A simple move such as this will have far more impact than decriminalisation, and importantly, will protect patients, not the pharmacists.”
Miss Daly added: “Whilst it is claimed these proposals would bring pharmacists in line with other health professionals, this is not the case.
“The Duty of Candour, introduced last November, sent a very clear message throughout the NHS that there would be no excuses for covering up errors of any scale. That guidance, which says Health Trusts must always be open and honest with patients or their families when things go wrong that can cause harm, could not have been more different to what is now being suggested for pharmacists.
“These proposals will simply protect pharmacists from any kind of external scrutiny and accountability, and that would be a dangerous route to take.”