Nneka Catherine Mormah, registration number 2237158, has been warned by the General Pharmaceutical Council (GPhC) after incorrectly dispensing a high-risk, prescription-only immunosuppressant that “contributed” to a patient’s death.
On October 12, the GPhC’s investigating committee said a coroner’s inquest found that the 88-year-old patient died of natural causes “contributed to by an error by the pharmacy” concerning the “dose and quantity of the medication”.
The determination document said Mormah was the locum responsible pharmacist, assisted by a dispenser, on January 17, 2025, when she dispensed 98 tablets of methotrexate rather than the prescribed 14 tablets.
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It said the patient’s handwritten prescription from a dermatologist was for methotrexate to be taken weekly on Mondays as an incremental dose, as well as folic acid on Fridays, but the weekly dose was “erroneously dispensed to be taken daily”.
And it noted that the error was not identified “at the point of calculation, dispensing or the final accuracy check” and the methotrexate was subsequently dispensed to the patient.
“Extensive skin damage”
The GPhC said the patient attended the emergency department on January 31 with “raw and ulcerated skin that was bleeding”, and was treated for “extensive skin damage secondary to overdosing on methotrexate”.
He was in “significant discomfort” from skin inflammation and mouth ulcers, it added.
The regulator said arrangements were made on February 3 to admit the patient to the intensive care unit after he “was found to have stopped breathing”, but as the patient did not wish for CPR to be attempted, he was “pronounced dead”.
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The GPhC’s investigating committee said methotrexate was “a factor in his death”, with the coroner’s inquest finding that the dose and quantity dispensed to him had “contributed”.
The patient had taken 65mg of methotrexate over an 11-day period, rather than the intended 12.5mg, it said.
“Inadequate” checks
The committee said issuing 98 tablets to an elderly patient who was “not stable on treatment” was “highly unusual” and “is likely to have presented a risk of harm”.
It added that Mormah did not “consider the length of treatment”, question the quantity prescribed or “monitoring” with the patient and prescriber, and said the prescriber “should have been contacted prior to dispensing”.
It said “rigorous monitoring and counselling are required” for the prescription of methotrexate, as well as checking the patient understands the instructions, but this “was not done”.
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And it noted that counselling on the safe use of the drug should have clarified which day of the week to take it, “which would have identified it as a weekly dose”.
The patient medication record system ProScript also “alerted the pharmacy team” to the weekly prescription of methotrexate and the need for “regular monitoring and blood tests”, and it “required acknowledgement prior to dispensing” that the medication should only be dispensed weekly and of its “high-risk nature”.
The committee said the clinical check “does not simply involve issuing the quantity prescribed”, adding that “no discussion took place with the prescriber or patient” about issuing 98 tablets.
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It highlighted that methotrexate should be used “with extreme caution in elderly patients” and that patients should be reminded of the once-weekly dosing because of the “risks of [a] potentially fatal overdose” if they take more than they should.
The committee also said the checking process was “inadequate”, with folic acid being prescribed weekly on the same prescription when it is recommended to be taken on a different day to the methotrexate dose.
And it noted that Mormah did not check if the patient had an alert card or methotrexate booklet when dispensing the prescription, “despite it being good practice”.
“Not be repeated”
The committee said Mormah “potentially breached” three GPhC standards and warned her that “such conduct must not be repeated”.
It reminded her that she must meet the statutory obligations of a responsible pharmacist or superintendent pharmacist “at all times”, and that any repetition of “this or similar conduct will likely result in further regulatory intervention”.
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The warning will be on the register for 12 months.
Read the determination in full here.
