NI Pharmacist Struck Off After Supplying Propranolol Instead of Prednisolone Leading to Patient Death
Date of Decision: May 18, 2015
Registrant's Role: Pharmacist
Allegations:
- The registrant dispensed Propranolol 40 mg instead of the prescribed medication Prednisolone 5 mg on 6 February 2014 at Clear Pharmacy, Antrim Health Centre. This constituted the supply of a medicinal product that was not of the nature or quality specified in the prescription, contrary to the Medicines Act 1968.
- The registrant failed to follow the pharmacy’s Standard Operating Procedures (SOPs) relating to Assembly and labelling of medicines and Accuracy checking during the dispensing process.
- The registrant was criminally convicted at Antrim Crown Court on 25 October 2016 for supplying a medicinal product in pursuance of a prescription that was not of the nature or quality specified in the prescription, contrary to sections 64(1) and 67(2) of the Medicines Act 1968. The registrant received a four-month prison sentence suspended for two years.
Outcome: Following a review of an existing suspension order, the Committee determined that suspension would not adequately protect the public. The registrant was therefore struck off the register with immediate effect.
GPhC Standards Breached:
- Standard 1 – Provide person-centred care
- Standard 5 – Use professional judgement in the interests of patients and the public
- Standard 6 – Behave in a professional manner
Case Summary
Allegations
The case arose from events on 6 February 2014 at Clear Pharmacy in Antrim Health Centre, where the registrant was the pharmacy manager and responsible pharmacist. A prescription was presented by Patient A’s husband for several medications, including Prednisolone 5 mg tablets. Prednisolone is a corticosteroid commonly prescribed for inflammatory conditions and is typically administered in short courses at specified doses.
The pharmacy’s Patient Medication Record indicated that 40 tablets of Prednisolone 5 mg were dispensed. However, a critical dispensing error occurred. The dispensing label intended for Prednisolone was mistakenly attached to a box of Propranolol 40 mg tablets.
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- Full allegations considered by the GPhC
- Panel findings and reasoning
- Outcome of the investigation
- Sanctions considered and imposed on the Pharmacist
- Key professional learning points
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