Pharmacist issued warning after baby ‘tragically’ overdosed on morphine
A pharmacist has been issued a warning by the regulator after a baby in palliative care was accidentally administered 20 times the correct amount of morphine.
Pharmacist Izabella Polyak, registration number 2069869, contributed to the death of a baby after she dispensed a “confusing and unusual” prescription for morphine, a General Pharmaceutical Council (GPhC) fitness-to-practise (FtP) committee heard on May 7-10.
A determination document revealed that in August 2020, Millennium Pharmacy in London received a “special” prescription of morphine “provided specifically” for Baby A, who had been recently discharged from Evelina Hospital for palliative care at home.
It added that the “uncommon” prescription sent by a GP surgery to the pharmacy included two different concentrations of morphine – one was for 10 mg/ 5ml oral solution and the other for 100 mcg/ ml.
The committee heard that the pharmacy dispensed the 10 mg/5ml oral solution “as morphine sulphate 100 mcg/ ml was not available on EMIS formulary” - something Polyak admitted that she did not explain to the baby’s father when he picked up the medicine.
When the baby’s mother administered the medication, “the baby became unresponsive and was taken by ambulance to hospital where tragically she died a few days later,” it heard.
The committee said that the errors “occurred during the COVID-19 pandemic…in a pressured environment” and that Polyak had “a long career as a pharmacist with no previous FtP concerns”.
But it found that she failed to ensure the medication was correctly labelled, check the concentration with the prescriber or “take any or sufficient steps” to advise Baby A’s parents.
“Three serious incidents in the last three years”
The committee heard that after an inquest held at Southwark Coroners Court in July 2023, the coroner concluded that Baby A died “of a combination of natural disease and accident”.
The coroner added that “the failures of both the GP and pharmacist to make further enquiries to ensure the medication administration was safe related in part to the workload pressures of the pandemic”.
But both “contributed to the death, as the child was given a more concentrated form of morphine that delivered 20 times the intended dose,” they said.
“Baby A was very fragile with limited life expectancy but would not have died when she did without the overdose,” the coroner added.
The coroner also found that the error would not have occurred had “another strength of morphine been a choice on EMIS”.
The committee heard that the senior coroner “notified EMIS with a view to the special prescription being added to its database”.
“He understood that a similar incident had occurred in the North of England and that lessons from the incident affecting Baby A had not been applied there,” it added.
And the committee heard that in November, the national medical director for NHS England (NHSE) revealed that “there had been three serious incidents in the last three years where an incorrect oral morphine preparation was prescribed and dispensed to a baby”.
“An isolated, albeit serious, series of errors”
The GPhC found that there was “no concern relating to Polyak’s honesty or integrity” and that she had offered her “deepest sympathies” and “heartfelt apologies” to the patient’s family.
It also found that she had demonstrated “highly developed insight”, testimonials from her colleagues had confirmed her “diligent and safe working practices” and that she “poses no risk to the public”.
She admitted all allegations and accepted that the prescription was “confusing and unusual and that she should have contacted the GP to clarify”, it said.
And it added that she has “sought to limit future risk by taking appropriate remedial actions and undertaking appropriate training”.
Polyak now “no longer takes phone calls during the prescription process”, “a trainee now assists her with her work”, and she “spends longer to check each prescription and discuss instructions with patients whenever necessary, regardless of whether there is a queue”, it said.
“She has a direct line to the GP surgery, so that she can raise questions with prescribers quickly” and “has moved to a branch of the pharmacy that is less busy and where she is less pressured,” it added.
But it said that Polyak’s errors “exposed Baby A to an unwarranted added risk of harm, in addition to the risks already faced by the vulnerable infant” and decided to issue her a warning.
“This can properly be regarded as an isolated, albeit serious, series of errors,” it added.
Read the determination in full here.
