A hospital pharmacist has been suspended for six months for repeatedly making dispensing and checking errors, some of which could have caused "serious harm" to patients.

Rhys Hywel Guard, registration number 2076255, made 19 errors between December 2011 and January 2013 at Great Western Hospital in Swindon, the General Pharmaceutical Council (GPhC) heard at a fitness-to-practise hearing on January 29.

The GPhC accepted that Mr Guard had been newly qualified when he made the errors - which did not result in patient harm - had no disciplinary history and found it hard to cope with his workload. But it ruled that patient safety was “placed at risk by [Mr Guard's] deficient performance”.

Mr Guard first joined Great Western Hospital in 2011 just a month after qualifying as a pharmacist. After a probationary period and passing his dispensing and final checking audits, he was given a cardiac ward to manage, which the hospital deemed appropriate as most patients were stable and on similar drugs. But between December 2011 and March 2012, he made six dispensing errors, including dispensing prednisolone to the wrong patient, and labelling Parkinson’s disease medication co-careldopa with the wrong dosage instructions.

In March, the hospital's lead pharmacist met with Mr Guard to discuss the errors and an improvement plan was formulated. But Mr Guard made a further nine errors between then and August, two of which were "critical" and could have caused patient harm. He was taken off the dispensary and stopped from carrying out final checking audits. Mr Guard was referred for a formal performance hearing at the hospital, issued with a final written warning and placed under supervision in October.

While working under supervision, Mr Guard did not make any errors for three months and he returned to unsupervised ward duties in January.

But he made a "serious clinical error" that month when he failed to update a patient’s drug chart with a drug removal, despite correctly identifying that they should not have been prescribed both Dalteparin and Rivaroxaban due to the risk of bleeding. Mr Hywel resigned from his position in February 2013.

The GPhC accepted that Mr Guard had co-operated with attempts to improve his performance and had always recognised his mistakes once they had been raised. It also noted that he had “good clinical knowledge” and that Mr Guard reported his mistakes had occurred “during extremely busy times when staff were under pressure”.

He had expressed a wish to practise as a community pharmacist, as he believed he would be better suited to this role, and was willing to undertake further training, the regulator heard.

But the GPhC considered that issuing Mr Hywel with a warning was “wholly inappropriate to address the issues in this case” and ruled to suspend him for six months with a review at the end of this period. At the hearing, Mr Guard would have to prove he was fit to practise, as well as demonstrating insight and the steps he had taken to remedy deficiencies in his performance, the GPhC said.

Read the full determination here.

 

 

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