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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.
It was more than five months before the pharmacy's SOP was changed in accordance with the recommendations of Medsafe and the Pharmacy Council, she said.
She was also concerned that Mr Barron still did not consider that there was ever anything wrong with the SOP.
"Mr Barron's statement [in response to a provisional report] that the SOP was `self-evident' leaves me with some disquiet that he still does not fully grasp the point being made about the importance of having clear written guidelines and detailed instruction in place for staff."
Ms Lamb noted that Campus Pharmacy and all other pharmacies owned by Mr Barron as part of the Mackenzie Group had subsequently implemented appropriate SOPs.
She ordered Mr Barron to write a letter of apology to Mr Wilson's mother, Donna Letham.
Approached for comment, Mr Barron said he did not see any point in relitigating the matter. He had made his differences with the findings of Ms Lamb clear.
Although he disagreed vehemently with the conclusions made, the matter had to be brought to a close.
Mrs Letham said a two-paragraph letter of apology was received yesterday, but the family was still concerned Mr Barron had not got the message.
"His apology is pathetic. He only did it because he was ordered to and can't even come and see us face to face."
Mrs Letham said she and her former husband, Michael Wilson, were pleased about the report, which they felt vindicated their son by showing that "it wasn't all his fault".
Mr Wilson said the family would seek other avenues for penalties.
Ministry of Health quality and safety manager Rose Wall said no-one had been penalised or fined for the incident because the pharmacy had changed hands.