The first tears came as the Court of Appeal heard how Carmel Sheller had collapsed after taking propranolol instead of the prednisolone prescribed. Elizabeth Lee dabbed her eyes, lent into her father for comfort, and probably wished for the billionth time that she could have put the clock back to August 2007. It was then that a diligent, 20-something pharmacist handed out a prescription for beta blockers instead of steroids. It had been a long shift, she momentarily slipped beneath her own high standards, and she made a mistake. Of course you feel for Ms Sheller’s family. Ms Lee’s mistake can’t be brushed aside and forgotten about. A grandmother’s health suffered as a result and she later died – of an underlying condition and not the error. If that was my grandmother or yours we would feel angry and want justice. But my overriding sentiment after attending Ms Lee’s Court of Appeal hearing last week is that justice hasn’t really been served. Everything indicates Ms Lee is an exceptionally honest and dignified person. She quit as a pharmacist as soon as her error came to light. She has shunned the limelight – repeatedly stressing her desire to pursue a quiet life. In the limited conversations she has had with C+D she has always spoken of her sorrow for what she did, extended her condolences to Ms Sheller’s family and never tried to make excuses. One of the appeal court judges made a telling counter attack to this argument. He drew a parallel to careless driving. You can be an upstanding citizen, but if you momentarily take your eyes off the road and cause an accident then you have to face the consequences. That might be true, but what if the accident took place on a particularly hazardous piece of road? Would it not be better to tackle road safety instead of making the driver a scapegoat?For Ms Lee the personal cost of this case has been vast. It was impossible to reconcile the wan individual who sat before the court last week with the vibrant woman of three years ago. In the quest to avenge one life, another has been destroyed. A one-time talented pharmacist now works as a cleaner for a local church, the court heard. That seems a tragic loss for both pharmacy and society as a whole.Thankfully, the Court of Appeal offered some redemption: it quashed Ms Lee’s custodial sentence. One avenue for prosecuting errors has been partially plugged thanks to Ms Lee’s appeal. It’s up to us to complete the job and ensure her legacy (p10) is as the pharmacist who brought an end to criminal prosecutions for dispensing errors.