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Xrayser: The coroner’s call was a reminder of why we keep records

“Could we have dispensed two citalopram doses in error?”

One year after a patient died from a citalopram overdose the pharmacy team had to dig out medical records to send to the coroner, says Xrayser

One of my patients – let’s call her Pauline – was a lovely lady in her 50s with mild learning disabilities, chronic alcoholism, and a schizoaffective disorder that meant her drugs were dispensed into an automatic discus-shaped monitored dosage system (MDS).

At set times this battery-powered device sounds an alarm, flashes a light, and rotates a tray so the dose can be tipped out. Bemused and anxious in equal measure, Pauline referred to her device as “Star Trek”. For years, it allowed her to boldly go where she had not gone before until one week when she didn’t pick up her prescription and we were told, somewhat awkwardly by her GP surgery, that she had died.

That was all the information we had until a year later came a phone call from the coroner’s assistant who opened with “GDPR requirements don’t apply to the dead, so you can give me all your information about this patient”.

The pharmacy technician who took the call was, however, schooled in our strict confidentiality procedure and declined to give out any information.

“I suggest you speak to the pharmacy superintendent,” I heard her say with such an ominous look and tone that I feared for what might be about to hit the fan. I was relieved when just a contact email address was requested.

The phone had barely been put down before a few staff members began speculating: “I told you it was strange.” “Why has it taken this long?” “What do they want from us?”

What they wanted from us was a formal report to the coroner with full patient medical records (PMR), and a list of specific points to address. This included a statement describing how the MDS device works, the dispensing process in detail, and what checking procedure was in place. Finally, in case we were in any doubt about the reason for these questions, it said: “Cause of death: acute toxicity of citalopram.”

At this point, the cold reality of consequences came home. Everyone tried to remember and reassess actions and procedures that a year ago had seemed everyday. Along with many other drugs, Pauline was on 40mg of citalopram, so we couldn’t have made a dispensing error of too high a dose – but could we have dispensed two doses in error?

A Google search revealed an article about responding to coroners that advised to be factual, clear, precise and prompt. However, to do so took me a whole day of gathering and retrieving PMR data and other documents requested.

The report was sent off, its promptness receiving a grateful acknowledgement but no suggestion of further process. We are still waiting. Much to the disappointment of the staff, we are unlikely to be informed of the outcome, so we just wait to see if I am called to give evidence in person.

Whatever the outcome, it was indeed a salutary lesson about the importance of evidence keeping and another reminder of the seriousness of what can seem the most routine dispensing task.

A long-running C+D contributor, the identity of Xrayser remains a mystery, but his irreverent views are known by all. Tweet him @Xrayser


Leon The Apothecary, Student

Incidentally, it is my opinion that pharmacy is terrible when it comes to record-keeping beyond dispensing records. Near-misses, consultations, queries - these are all things that the pharmacy does not record consistently.

Pharmacy is also quite outdated in other aspects of record-keeping. Private medical book and control drug registers are by the large majority, physical when there is a strong argument that digital is quicker, more robust, safer, and enables many more features.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

The pharmacy technique for recording near misses - one, two, miss a few, three four, miss some more....

There's too much emphasis on recording everything nowadays and we quite simply don't have the time. I know if there was ever a dispensing error and you had no recorded near misses, it would look like you aren't doing your job properly, but who can say, hand on heart they record every near miss and every trivial dispensing error that comes their way? Even the definition of 'near miss' and 'dispensing error' is open to interpretation.

Total, 100% agreement about the CD register - it's like something pre-ark, let alone out of it.


Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

This is just one of the legion of reasons why I'm not renewing my registration this year.

To be fair, this person MUST have been saving up their tablets for a serious suicide attempt - citalopram is not THAT toxic that taking an extra one would kill you, and besides which, Mr Xrayser, don't worry because the evidence has been eaten!

Caroline Jones, Community pharmacist

Maybe; but 40mg OD is off licence if co-prescribed with other medicines that have the potential to prolong QTC, or if she had any cardiac conditions........

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

GP should know about that then. All you'd need to record on the PMR is that you'd pointed that out to the doctor. I think the fact that this particular patient is (or was) alcoholic could be a major contributary factor - 20mg is the max dose in mild to moderate hepatic impairment, so if her liver was shafted after her alcoholism, that's probably what happened, but again, the GP should know about that.

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