Deputy Health and
Disability Commissioner Rae Lamb has found the former Campus
Pharmacy in Dunedin and its then owner, Peter Barron,
breached a man's rights to have services provided with
reasonable care and skill after he was dispensed somebody
else's methadone and later died.
In March 2006, Christopher Wilson died after taking six times
more methadone than prescribed when he was handed, and
accepted, someone else's dose by a dispensing pharmacist who
wrongly identified him on sight. .
In a report to be released publicly shortly, Ms Lamb has
found the pharmacy and its then owner breached Mr Wilson's
rights to have services provided with reasonable care and
skill under the HDC Code of Health and Disability Services
The report was released to the Otago Daily Times by Mr
Campus Pharmacy did not have adequate procedures for
identifying methadone clients in place at the time of Mr
Wilson's death, Ms Lamb found.
Investigations into the dispensing pharmacist's actions were
discontinued in December 2007, after taking into account his
acceptance of responsibility for the mistake, his poor
health, and Ms Lamb's technical adviser's recommendation that
while he did not provide adequate care for Mr Wilson, the
service he provided was common practice in that pharmacy.
Ms Lamb found that Mr Barron believed a requirement to
identify clients by asking them to state their name or
address had been made clear to staff, but was not written in
the pharmacy's standard operating procedure (SOP) for
identifying methadone clients at the time of Mr Wilson's
Three senior staff members told her it was accepted practice
to identify the client by recognition alone.
"In the circumstances, I am not convinced that pharmacy staff
had been given clear guidelines or instruction on how to
confirm the identity of the patient," she said.
She concluded it was the pharmacy's responsibility to ensure
relevant professional standards were met through the
development and implementation of SOPs.
"It is not enough to rely on reminders to staff to be
vigilant, particularly in a busy pharm-acy dispensing
methadone to up to 100 clients."
The fact two other pharmacists had also previously mixed up
methadone clients testified to the need to remove any
subjective judgement from the system and provide detailed
written instruction, she said.
Ms Lamb said she was disappointed the Campus Pharmacy was not
"proactive" about improving the SOP covering
methadone-dispensing procedures following Mr Wilson's death.