terry Maguire o

n 6 february 2014, Mrs Ethna Walsh, a 67-year-old grandmother from County

Antrim, was prescribed prednisolone tablets 5mg by her doctor to treat an exacerbation of a respiratory condition at a dose of 40 mg (eight tablets daily) for five days.

Having taken the first dose of eight tablets, she became ill, collapsed, was rushed to hospital and was dead within two hours. She had been dispensed propranolol 40mg tablets by mistake.

Martin White, her pharmacist, fully cooperated with the investigation and admitted that he had been responsible for all the dispensing steps. He is an experienced pharmacist and has worked in a busy dispensary for many years with no apparent previous dispensing errors.

He could not explain during police interviews how the error occurred. Dispensing errors in pharmacy practice occur at a relatively low frequency. According to a UK national Patient Safety Agency (nPSA) report of 22,000 medicines dispensed, there were 26 dispensing errors a frequency of approximately 0.1 per cent. Dispensing errors that cause harm to patients are at a lower rate still at about 0.02 per cent.

the nHS national Patient Safety Agency issued a freedom of Information letter in 2009, which


stated that, during the period January 2005 and June 2009, there were seven incidents reported relating to transposing of prednisolone for propranolol and vice-versa. the outcomes from these transpositions were: one death, one moderate harm and five no harm.

two of these reports were from community pharmacy and five were from hospital. the death and moderate harm reports were from prednisolone being transposed for propranolol (as it was in this case) but are very rare nonetheless.

Similar named drugs juxtaposition on pharmacy shelves are a main source of dispensing risk and error, and pharmacy insurers identify the risk potential for transposition during the dispensing process regularly in correspondence with pharmacists. over 80 per cent of dispensing errors are picking errors, ie, selecting the wrong medicine.

following an investigation by the Police Service of northern Ireland, a file was submitted to Public Prosecution Service (PPS), which decided to take a case under the Medicines Act 1968. In court Martin White pleaded guilty.

It was hard to pinpoint why this tragic error occurred and the judge in the case agreed it was a ‘momentary lapse of concentration’. the judge found him guilty and sentenced him to four months in gaol, suspended for two years.

Martin White is a good man, a loyal, hardworking employee and, by most standards, a good pharmacist. He is now a broken man and has decided to leave the profession. I’m sure he never thought it would come to this.

over his 24-year career - most of it working in the same business - he never envisaged that, one day, he would make an error and kill a patient. the shock, the horror, the personal turmoil, the very public punishment, the criminal proceedings and a stiff sentence that seems excessive and disproportionate…

It’s also likely that Martin White will be asked to appear before Pharmaceutical Society of northern Ireland. All community pharmacists, apart from the righteously deluded, have made similar mistakes but - thankfully - with far less tragic consequences.

But Martin White is not the victim in all of this, you might think. A family lost a much-loved grandmother in the most tragic of circumstances and someone must take responsibility; the public must be protected. no one disagrees, but what is the price that must be paid by a professional person for a momentary lapse of concentration?

Mistakes, in any human endeavours, happen. We need systems to reduce risk and, when mistakes happen, we need to identify both the causes - and those responsible - and take steps to ensure similar mistakes do not

happen in the future. I don’t know which aspect of the criminal proceedings that have just concluded will give that public assurance.

the legal system in the UK is unfairly punitive on dispensing errors. Had a gP, dentist, social worker or community nurse made a mistake with similar consequences, they would not have been held criminally liable unless it could be proved they were guilty of gross negligence manslaughter.

Had a gP made a similar mistake with similar consequences, the PPS would be required to believe he or she was guilty of gross negligence manslaughter. gross negligence manslaughter would only apply where there was evidence of the doctor repeatedly committing the mistake and/or deliberately worked in a dangerous environment.

If this threshold was not reached, it becomes a professional regulatory matter. PPS did not believe that Martin White got anywhere near a threshold of gross negligence manslaughter, yet, because of the vagaries of the Medicines Act, he was subjected to criminal proceedings.

for a pharmacist a dispensing error is an absolute offence. By making a mistake, a pharmacist becomes a criminal. for many years, work has been on going to address this anomaly but the changes, long overdue, are too late for Martin White. •

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