Sunday, May 29th, 2016

Boots Pharmacy Dispensing Error

On Thursday 26th May, Sheriff Margaret Neilson issued her determination in the Fatal Accident Inquiry into the death of Margaret Forrest.

Mrs Forrest died after having been handed the wrong medication at Boots Pharmacy in Kingussie, in November 2013. The Inquiry heard that an error had occurred at the “handover stage” and in fact, Mrs Forrest had been given medication prescribed for another patient. Mrs Forrest took the medication, including gliclazide, which induced a hypoglycaemic brain injury leading to cardiac amyloidosis.

The sheriff noted, inter alia, that: “A significant part of the inquiry was devoted to hearing evidence on the Standard Operating Procedures employed by Boots UK Ltd (“SOPs”).  There was detailed evidence from all members of Boots’ staff in Kingussie who gave evidence, and from Dr Moss, in relation to the Boots SOPs.  It was clear from all staff that they understood fully what the SOPs required them to do. […] The error in this case appears to have happened at the handover stage.  There was a failure by a member of staff to reconcile the name and address details of the patient with what was on the pack that was being handed over.  A three-way check of those details is required and is outlined in the SOPs but that did not happen in this case.  The check is outlined in the Boots Standard Operating Procedures 006 version 5 (Crown production 11 and appendix 4 to Dr Moss’s report) and the steps are clearly laid out. […] If the Standard Operating Procedures in existence at the time had been followed, the accident would not have happened.”

Accordingly, the sheriff accepted the submission made on behalf of Boots and held, in terms of section 6(1)(d) of the Act that “there was no defect in the actual system of working.  Had the prescribed system been followed correctly the accident would not have happened.”

Relying on the evidence of ­­­­­­­­­­­­­­­­­­­­­­Dr Jose Moss, deputy superintendent pharmacist for Boots, the sheriff declined to make any finding under section 6(1)(e) of the Act, or to make any of the recommendations contended for by the Crown or the family of the deceased.

A copy of the Determination can be found here.

Barry Smith of Compass Chambers represented Boots (UK) Ltd.

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