Elizabeth Lee did not cause the death of the patient when she made the dispensing error that led to her criminal prosecution and suspended jail sentence, a coroner’s inquest has found.In a narrative verdict, Berkshire coroner Peter Bedford said “on the balance of probabilities” 72-year-old Carmel Sheller died from her underlying conditions, and not because of a dispensing error that saw her take propanolol tablets rather than prednisolone three days earlier. Mrs Lee was handed a three-month suspended sentence last April over the incident. However, post mortem blood samples had shown only trace amounts of propanolol, and the effects were likely to have been “so minimal” at the time of death they could be “discounted as having any material effect”, Mr Bedford said.The result, recorded at Windsor Guildhall last week, now clears the way for Mrs Lee’s planned appeal against the conviction and sentence later this year, as revealed by C+D last week (March 6, p4).
The Pharmacists’ Defence Association (PDA), which represents Mrs Lee, was “very pleased with the result”, said chairman Mark Koziol, adding the verdict created “no real problems” for the appeal.
In delivering his verdict, Mr Bedford said he had written to the RPSGB, Department of Health, NPSA and MHRA, urging them to consider a series of sweeping reforms to improve medicines safety. Changes suggested in the letter include providing a second copy of the prescription to be kept by the patient, colour-coding of dangerous medicines and measures to ensure a medicine is always checked by two people before it is dispensed.However, Charles Russell LLP solicitor David Reissner said that he believed Mr Bedford’s recommendations were “pointless”.He said: “The coroner didn’t hear evidence from anyone qualified to give him the full background to these issues; and if they could be resolved simply, it would have been done long ago.”Speaking exclusively to C+D, Mr Bedford added that he was putting forward suggestions raised by Mrs Sheller’s family, and was “just throwing out some general ideas” to improve medicines safety. The Society and MHRA said they had not received Mr Bedford’s letter as C+D went to press.