As 2016 draws to a close, I would like to be able to say that the sector’s greatest achievement this year was to see the threat of criminal sanctions for inadvertent dispensing errors removed once and for all. 

Yet almost four years since the Department of Health set up a programme board tasked with decriminalising inadvertent dispensing errors, it remains tantalisingly out of reach. This was brought back to the forefront of my mind by the case of Northern Irish pharmacist Martin White. According to the BBC and ITV, Mr White – of Belfast Road, Muckamore, County Antrim – is currently waiting to be sentenced for an alleged dispensing error in the hours leading up to the unfortunate death of a 67-year-old patient in 2014.

This case genuinely frightens me. It feels quite close to home – literally, as it occurred 20 minutes from where I first worked as a pharmacist in Northern Ireland. It could have been me, I have made mistakes in my time.

This is a tragedy. The suffering of the patient’s family cannot be comprehended, and I imagine the grief of the pharmacist will be beyond words. The thing is, I was not shocked by the BBC’s report – in fact, I was surprised that more incidents like this have not occurred.

In the case of Mr White, propranolol was given out on a prescription for prednisolone. With the correct checks in place, dispensing errors of this nature should never occur – we can all agree on this. However, according to the BBC, the court heard that there were a number of other factors which could have played a role: fatigue, tiredness and similar-looking boxes. These factors are all a routine part of working in community pharmacy.

In my experience, when a pharmacist does make a mistake, it tends to be resolved quickly – with many apologies being made. However, it raises the question, if dispensing errors are an inevitable part of a pharmacist’s role, surely this should be factored into the legislation that governs our profession?

Since locum Elizabeth Lee was handed a prison sentence for a single dispensing error in 2007, there have been a plethora of delays and excuses around this most important issue. By the end of 2014, parliamentary lawyers were approving draft legislation to create a legal defence against prosecution for inadvertent dispensing errors. So why in June this year did we hear from the Royal Pharmaceutical Society (RPS) that Brexit could pose the latest obstacle to decriminalisation?

Now I admit that while the risk of a criminal sanction for a dispensing error used to terrify me as a newly-qualified pharmacist, in recent years it has been replaced with other concerns – such as establishment payments, locum rates and staffing issues.

But the case of Mr White has reminded me how trivial these worries are, when I could go to prison – and worse, feel the responsibility for someone’s death – for lifting the wrong box off the shelf.

The question is, where do we go from here? I don’t know the details of Mr White’s ongoing case, but it is a timely reminder that the looming fear of criminal sanctions for an inadvertent mistake hangs over us all.
 

Kristoffer Stewart is CPD and clinical editor of C+D, and a locum community pharmacist. Email him at [email protected] or contact him on Twitter at @CandDKristoffer