Locum warned after dispensing error in ‘staffing crisis’ leads to patient death

A locum responsible pharmacist has been issued a warning after a patient died when he dispensed the wrong strength of oxycodone during a staffing crunch, the regulator has revealed.

Paresh Gordhanbhai Patel supplied 120mg rather than the prescribed 20mg of oxycodone hydrochloride to an “elderly” patient while working two locum shifts as responsible pharmacist at Crompton Pharmacy at Whitley House Surgery in Chelmsford.

After taking one tablet, the patient died from an “accidental” oxycodone “overdose”, the General Pharmaceutical Council’s (GPhC) fitness-to-practise (FtP) committee heard at a hearing held on 11-13 September.

Mr Patel admitted that he was “stressed and overtired” when he failed to notice a “discrepancy” between the prescribed strength of oxycodone and what he ordered and dispensed,

The regulator heard that Mr Patel was “over-conscientious” and felt compelled “at a human level” to help out at the under-staffed pharmacy, despite the fact that it was “not safe to do so”, it added.

Mr Patel admitted that his errors “amounted to misconduct” and conceded to the committee that his fitness to practise was “impaired” because he “breached one of the fundamental principles of the pharmacy profession.”

The regulator heard that Mr Patel had “immediately” admitted his mistake to the pharmacy and did so again at the coroner’s inquest, where he also publicly apologised to the patient’s family.

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Source: Chemist and Druggist, 12 October 2023