A Lloydspharmacy pharmacist has been given an official warning for failing to take adequate action to correct a serious medication error.

Manhar Prabhubai Patel, registration number 2018623, failed to act urgently on his suspicions of a warfarin error because he had a "great deal of faith" in his team's checking abilities, the General Pharmaceutical Council (GPhC) heard at a fitness-to-practise hearing on December 4.

The GPhC said Mr Patel, who was convicted by a magistrates' court for the dispensing errors last year, was a "very straightforward and honest witness" who was full of remorse. It ruled that he had insight into what went wrong and warned him to take "immediate and effective" action if a similar situation occurred in future.

The GPhC found that Manhar Prabhubai Patel, registration number 2018623, had failed to take adequate action to correct a serious medication error	More on fitness to practise Pharmacist suspended for illicit drug use Former Lloyds manager jailed for stealing £400,000 of drugs and equipment Pharmacist struck off for sexually assaulting student MORE NEWS
	Mr Patel worked at a Lloydspharmacy branch in Bishops Waltham, from which he regularly dispensed a special dose of warfarin for a care home patient. The patient was prescribed a strength of 1mg in 5ml, which had to be made as an unlicensed special.

In spring 2011, a licensed warfarin suspension became available at a strength of 1mg in 1ml – five times the patient's prescribed strength. When pharmacy staff tried to order the same 1mg in 5ml strength from the specials supplier, they were repeatedly told there was a licensed product available, the committee heard.

The pharmacy's regular dispenser was aware of the situation and insisted on the correct strength each time she ordered. But in May, while Mr Patel was not on duty, a different dispenser made the order and she was supplied with the 1mg in 1ml strength.

Mr Patel made a clinical check on the products when he returned from holiday two days later but failed to spot the difference in strength and the medication was supplied to the patient. Two weeks later, he overheard a dispenser ordering the product at the special strength and he started to query the dose given to the patient.

Mr Patel told the GPhC that he worried about the issue that night and phoned the care home the next day. The person responsible for drugs administration was not there so he called back the following day, when he was told the patient had died.

Mr Patel was "very shocked", the GPhC heard, and did not raise the issue for two days. He then spoke to the pharmacy's dispenser about the possibility of an error and went on to tell the pharmacy manager, when he was described as "extremely upset".

Mr Patel pleaded guilty to supplying a drug not in the nature specified in the prescription at Southampton Magistrates Court in July last year. The GPhC did not gave details of the sentencing and stressed that it was not examining the error itself or whether it had caused or contributed to the death of the patient.

The GPhC found that Mr Patel had failed to take adequate action when he discovered the possibility of an error. But the fitness-to-practise committee said it had the "overwhelming impression" that Mr Patel trusted the team's checking systems and was reluctant to believe they had made a mistake.

The GPhC heard testimonials from colleagues describing Mr Patel as a "caring and conscientious pharmacist", and noted that his fitness-to-practise had not previously been called into question in his career of more than 40 years. It accepted the incident had a "profound and devastating effect" on Mr Patel, who bitterly regretted his actions.

The GPhC deemed there was a low risk of Mr Patel making a similar mistake and gave him a warning to address any errors immediately in future.

Read the full case here.

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