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Locum warned after dispensing error in ‘staffing crisis’ leads to patient death

A locum responsible pharmacist has been issued a warning after a patient died when he dispensed the wrong strength of oxycodone during a staffing crunch, the regulator has revealed.

Paresh Gordhanbhai Patel, registration number 2043480, supplied 120mg rather than the prescribed 20mg of oxycodone hydrochloride to an “elderly” patient while working two locum shifts as responsible pharmacist at Crompton Pharmacy at Whitley House Surgery in Chelmsford, according to a hearing document.

After taking one tablet, the patient died from an “accidental” oxycodone “overdose”, the General Pharmaceutical Council’s (GPhC) fitness-to-practise (FtP) committee heard at a hearing held on September 11-13.

 

“Stressed and overtired”

 

Mr Patel admitted that he was “stressed and overtired” when he failed to notice a “discrepancy” between the prescribed strength of oxycodone and what he ordered and dispensed, the document said.

The regulator heard that Mr Patel was “over-conscientious” and felt compelled “at a human level” to help out at the under-staffed pharmacy, despite the fact that it was “not safe to do so”, it added.

Read more: GPhC: Almost all whistleblowing cases last year linked to community pharmacy

Mr Patel admitted that his errors “amounted to misconduct” and conceded to the committee that his fitness to practise was “impaired” because he “breached one of the fundamental principles of the pharmacy profession”, it said.

"I had hoped to end my career with my head held high and a record that was unblemished,” he said.

“I am prepared to follow whatever guidance or conditions the GPhC deems necessary to satisfy the public's faith in me as a pharmacist and to maintain the integrity of this wonderful profession,” he added, apologising for “bringing [the profession] into disrepute".

 

“Haunts me to this day”

 

The regulator heard that Mr Patel had “immediately” admitted his mistake to the pharmacy and did so again at the coroner’s inquest, where he also publicly apologised to the patient’s family.

In a written statement, Mr Patel said he was “completely devastated” about the “terrible mistakes” that led to the patient’s death by oxycodone overdose.

Mr Patel told the committee that his failure to check the prescription after the patient’s daughter raised concerns about the prescription was “something that haunts me to this day”. 

While the “exact words” used by the patient’s daughter to check on the prescription with Mr Patel were “not agreed”, the committee found that he had “narrowly interpreted” her question about the “dose” to refer only to how often the drug should be taken and not its strength.

Read more: Health secretary alerted as GPhC fails FtP standard for fifth consecutive year

The regulator found that Mr Patel’s “failure to listen actively” had led to “catastrophic consequences”.

In testimonials provided to the regulator, Mr Patel was described as an “exemplary” pharmacist who was “process driven” and whose expertise gave him “good judgement”. 

The regulator heard that “no other concerns” had been raised against Mr Patel in his 24 years of registration before the dispensing mistake, nor any in the four years that followed.

 

“Staffing crisis”

 

Nevertheless, the regulator found that a patient had died as a result of a “series of avoidable errors” made by Mr Patel.

It found that he had been working an “excessive” number of hours and that he “made an error in his professional judgement in agreeing to work to help out in a staffing crisis at Crompton Pharmacy”.

Read more: FtP concerns from public spike as pharmacies see ‘increased pressures’

This mistake was “compounded” by his decision to dispense oxycodone, a controlled drug, without a second checker present at the pharmacy, it added.

Not only had Mr Patel made a mistake on the label of the patient’s prescription and ordered stock on that basis, but he had “missed the opportunity” to check the dispensed medication against the patient’s prescription.

The regulator found that his response to the patient’s daughter’s concerns was “lacking”, as he should have noted her query as a “red flag”.

 

Dispensing error

 

On November 11 2019, Mr Patel had been asked to pick up a daytime locum shift at Crompton Pharmacy after its “usual” pharmacist had “suffered a bereavement”.

Mr Patel had been working at the pharmacy as a locum since May of that year but typically in the evenings and at weekends since he also ran an online pharmacy business in Southend on Sea, the regulator heard.

Mr Patel made a mistake as he prepared the label for an elderly patient’s controlled drug prescription, possibly as a result of “inadvertently” pressing the ‘1’ and ‘2’ keys simultaneously on the computer.

Read more: GPhC: Pharmacist handed warning over 'antisemitic' remarks at political rally

He ordered stock for 56 tablets of 120mg oxycodone, rather than 56 tablets of 20mg oxycodone, according to the evidence submitted, which was accepted by Mr Patel.

While Mr Patel had not planned to work at the pharmacy the following day (November 12), he was asked in the morning to fill in for a locum pharmacist that had not turned up for a shift.

He arrived at the pharmacy after the controlled drugs had been delivered for the day and as the only other staff member was a trainee dispenser, Mr Patel was the only person who could check prescriptions for controlled drugs, the FtP committee heard.

Read more: ‘Manipulated’ pharmacist suspended for dispensing fraudulent fentanyl scripts

When the patient’s daughter came to the pharmacy to collect her mother's prescription, Mr Patel collected the 120mg oxycodone from the pharmacy’s cabinet, checked the box against the label he had prepared and handed it over.

The patient’s daughter raised a concern about the medicine and Mr Patel noted that the dose was correct but did not notice that the strength of the medicine was six times more than it should have been.

A coroner's inquest concluded that the patient died “as a result of an accidental overdose of oxycodone [that] was the result of a dispensing error of her prescribed medication”, although “serious natural disease also contributed to her death”, the hearing document said.

 

“Genuine remorse”

 

The regulator said that mitigating factors included that Mr Patel has “reflected deeply” and “shown genuine remorse” from an early stage as well as “insight”.

It added that he had “comprehensively remediated his errors” and that the committee did not believe that he posed a “risk to patients or the public”.

In the years that followed the patient’s death, Mr Patel had changed his practice and now circled the dose and strength on prescriptions and labels “as a precautionary measure”, reduced how much he worked and closed his online pharmacy business.

Read more: Locum handed three-month suspension for showing colleague picture of penis

The regulator heard that Mr Patel now prefers to take locum shifts at “larger pharmacy chains”, since these pharmacies have “contingency plans” to deal with understaffing.

Mr Patel had also taken “highly relevant” courses to develop his consultation skills and “reduce the risk” of making future errors.

But the regulator stressed that Mr Patel’s dispensing error had led to a patient suffering an overdose leading to their death.

Read more: ‘Overwhelmed’ locum suspended for four months over codeine payment mix-up

It said that an aggravating factor was a “background” of “errors of professional judgement" in his agreeing to work with “insufficient staffing” and to supply a controlled drug without a second checker.

It found him guilty of misconduct and determined that his fitness to practise was impaired on public interest grounds, saying that his errors had “brought the profession into disrepute”.

 

Warning issued

 

The regulator considered suspending Mr Patel from the register but found it “of greater concern” that to do so would “deprive the public of his evidently competent and caring services”.

Instead, the regulator issued a warning to Mr Patel, which will remain on its register for one year.

It said the warning was to “remind pharmacy professionals and the public of the standards that pharmacists are expected to meet at all times”.

Read the determination in full here

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