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Lawyer: Martin White's sentencing is 'shocking and wrong'

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Noel Wardle: There is no evidence Martin White's error caused the death

A leading pharmacy lawyer has condemned the severity of the punishment handed down to a pharmacist whose dispensing error has been linked to a patient's death.

Northern Irish pharmacist Martin White was sentenced to four months in prison, suspended for two years, at Antrim Crown Court last week (December 16). Mr White had admitted he accidentally dispensed propranolol instead of prednisolone to Ethna Walsh, 67, in the hours leading up to her death in 2014.

The imposition of a prison sentence for Mr White’s offence – even though it is suspended – is shocking and wrong”, Noel Wardle, a partner at law firm Charles Russell Speechlys, told C+D yesterday (December 20). 

Mr Wardle said there was “no evidence” that has been published that Mr White’s error had caused the death. Published evidence would have made it “likely” he “would have been charged with manslaughter, not an offence under the Medicines Act”, he said.

The case of Elizabeth Lee

Mr Wardle compared the sentencing to the case of pharmacist Elizabeth Lee, which he said was indistinguishable from Mr White’s. Ms Lee had made "exactly the same dispensing error" in 2007 preceding the death of a 72-year-old woman, but Ms Lee's final sentence in 2010 was a £300 fine. She had also pled guilty to dispensing propranolol instead of prednisolone, and been greatly affected by the death, Mr Wardle said.

Ms Lee had initially been handed a three-month suspended sentence in 2009, but this was reduced the next year following an appeal. The Court of Appeal ruled that the initial punishment had been “manifestly excessive,” as the drugs were not listed among the causes of death.

In Mr White’s case, the judge “should have been made aware” of the final verdict for Ms Lee, said Mr Wardle, as well as the government’s announcement that section 64 of the Medicines Act 1968 will be amended. This legislation is commonly used to instigate criminal proceedings against pharmacists.

"There is a world of difference between a suspended prison sentence and a modest fine," Mr Wardle said. “Martin White’s case highlights the government’s continued failure to act on its promise to decriminalise dispensing errors," he added. 

The need for decriminalisation 

This was echoed by Royal Pharmaceutical Society (RPS) president Martin Astbury, who told C+D pharmacists carry a "huge responsibility" to ensure that dispensing is as safe as possible.

Mr Astbury said he would like to see measures put in place so “one simple mistake can’t lead to such devastating harm to patients and their families”.

Mr Astbury stressed that pharmacists take any dispensing error "very seriously" and have "far too long" worked under the threat of criminal prosecution for making an inadvertent dispensing error. 

The RPS president said the society is working with the government and other pharmacy organisations to change the law regarding criminal prosecution, to which it is "100% committed". 

"The proposed change would bring pharmacists in line with other healthcare professionals, who do not automatically face criminal sanctions for human error," he added.

6 Comments
Question: 
How should the sector tackle dispensing errors?

Shawn Brotherhood, Community pharmacist

Sorry before anyone comments! there is a debate over pleaded or pled (or in fact plead!) I stand corrected.

Shawn Brotherhood, Community pharmacist

If we are into correcting errors perhaps someone can read the paragraph again and correct the obvious spelling mistake in the same sentence as the above should it not be pleaded not pled! Please take the time to check your work as the consequences can be considerable

Angela Alexander, Academic pharmacist

There is a serious error in the report above where it refers to Elizabeth Lee "She had also pled guilty to prescribing propranolol instead of prednisolone". It was a dispensing error not a prescribing error, which would of course been far more serious. Can this be corrected in the text?

Thomas Cox, Editorial

Thank you for pointing this out Angela, it has now been corrected. 

Robert Bradshaw, Community pharmacist

 

What a sad case for all involved - family and pharmacist / staff. Completely disproportionate sentence especially considering the Appeal Court ruling mentioned by Noel in the article.

Following a Rule 43 Report (now known as Prevention of future deaths report) from the Berkshire Coroner in 2011 Thames Valley Area Team asked all pharmacies to separate all prednisolone tablets from the other drugs in the dispensary. Perhaps NHS England could consider applying this to the rest of England. Quote from the report says the Berkshire Coroner asked the Secretary of State for health to consider changing the packaging for prednisolone

The report is here: https://www.judiciary.gov.uk/wp-content/uploads/JCO/Documents/coroners/pfds/Summary+Report+of+PFD+Reports+Apr+-+Sep+2013.pdf

N O, Pharmaceutical Adviser

If this rule applies then we may need a warehouse for every pharmacy or 20+ separate locked cabinets, so that all the high risk/ similarly looking medicines can be stored entirely away from the routine dispensing area !!!! Silly suggestion, just make sure these similarly looking/ sounding medicines are separated by 1 or 2 odd sounding low risk items, so that the overworked, stressed almost asleep deispeser/ pharmacist can dispense the right thing !!!

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