Pharmacy censured over man's death

Peter BarronDeputy 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 Consumers' Rights.

The report was released to the Otago Daily Times by Mr Wilson's parents.

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 death.

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.

ODT/directory - Local Businesses

CompanyLocationBusiness Type
Balmacewen SchoolDunedinSchools
Fisher WindowsDunedinDoors & Door Fittings
Health 2000 AlexandraAlexandraNutrition
Adventure RentalsWanakaVehicle Rentals