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Why the case of Martin White is a stark reminder for us all

"This case feels close to home – it occurred 20 minutes from where I first worked."

As a Northern Irish pharmacist awaits sentencing, we must not forget that inadvertent dispensing errors have still not been decriminalised, says C+D’s clinical editor

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

How should the sector tackle dispensing errors?

Joan Richardson, Locum pharmacist

I'm with all of above -the decriminalisation of dispensing errors has been delayed for far too long.  The GPhC and RPS DO NOT CARE enough to push for decriminalisation.

We are all human and therefore can make mistakes.  We are now working under increased pressure for longer hours and with fewer staff due to funding cuts so it is inevitable that there will be more mistakes.  Until this is sorted out there will be a reluctance to fill in an error log for fear of incriminating oneself.

Madni Sheikh, Locum pharmacist

Most likely the stock was picked by an untrained / trainee / shop floor staff to fill the gap and 'signed-off ' by him in a hurry as the patient might have been " waiting" a long time, due to shortness of staff. Another fallout of funding cuts.

PARESH shah, Community pharmacist

So now this government wants us to report all errors to get part of the money that has been taken away. I know which part I will not be chasing until decriminalisation takes place. Thank you.

Uma Patel, Community pharmacist

The reason why we don't have the legislation is that there are no votes in it for the politicians and our so called leaders don't push hard enough for it

Meera Sharma, Community pharmacist

My sympathies go out to this pharmacist. It's a shame that the process of decriminalising is dragging it's feet, it really does need to be pushed higher up the agenda. Having said that, our respective organisation are too busy allowing yet more pharmacy schools to open, so that there's more pharmacists working in factory-shop like conditions and then available at the drop of a hat for striking-off! Definately an esteemed profession that has been left out in the cold by our representatives - think a GPHC-exit is long overdue.

Anonymous Anonymous, Information Technology

And all for not much more than minimum wage these days... What a shocking demise of a once respected profession!

Valentine Trodd, Community pharmacist

Barry Pharmacist has alluded to the fact below and Kristoffer has also mentioned her name, but nobody seems to have picked up on it... the mistake that this poor fellow made is EXACTLY the same mistake Elizabeth Lee made - dispensed propranolol instead of prednisolone. Everyone should separate their prednisolone and propranolol, if they haven't done so already, and make sure we don't have a third occurrence of this deadly mistake.

Incidentally, I remember reading at the time about recommendations that manufacturers should change the packaging of the two products concerned because of similarities. Well, I've still got very similar little red and white boxes on my shelves... 

I also agree with Kevin. The current culture in community pharmacy IS a blame culture - it in no way whatsoever encourages you to own up to and admit your mistakes. The fact decriminalisation hasn't happened yet is a disgrace and the RPS & GPhC should be ashamed of themselves in this regard. Maybe they should put more effort into this than persecuting hapless pharmacists on the verge of retirement for doing illicit MURs.

Ian Kemp, Community pharmacist

Absolutely correct Valentine. Whatever the reasons for lack of action on decriminalisation there is simply NO EXCUSE for the lack of action on similar packaging and someone must be held to account for that truly criminal [ alas not illegal] inaction.

Barry Pharmacist, Community pharmacist

Terrible tragic case and there by the grace of God go I.  The case is similar to Elizabeth Lee in several respects. Long shifts and working hours (60hrs a week), cramped working space. Poor chap. Robots are not the answer. Having a culture and employer that supports staff to reduce the liklihood of errors to zero is required. Not something that very many places can afford to put in place due to funding cuts.

Kevin Western, Community pharmacist

first by accepting they will happen - it is inevitable - every process has a failure rate and if we get it 99% right or 99.9999999999999999% right its going to go wrong eventually. after that its down to learning and risk reduction which does not happen with punitive schemes - how can i be forced to reveal something which can get me a criminal conviction? it is just not a sensible way of doing things. 

To say tht our several "representative" organisations havent covered themselves in glory on this is something of an understatement! why arent the RPSGB not picketing Parliament, or doing something else vociferous? we have seen where not rocking the boat gets us - time to be nasty a bit more often...

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