A story of healthcare failures: A family member's view

Summary

Hi, my name is Andrew Payne.

In October 2019, my late wife Janice was in the palliative stage of her cancer when she was a victim of a dispensing error.

This was caused in large part by an intransigent pharmacist who refused me an emergency supply of medication for my wife a few days previously.

Failures by the pharmacy branch and Janice's GP meant she had to endure the side effects of ingesting the medication of a patient with the same surname as her. She will have suffered pain, discomfort and harm. This much has been admitted by the private pharmacy company involved.

I would like to share the series of events leading to my wife's death and after, and the actors involved and the questions that need to be answered.

Content

The pharmacy

As much as the pharmacy involved said "we take this kind of circumstance very seriously", the truth is that they worked very hard to see the case closed.

The pharmacy did not mention to me the failures of their staff to observe the Duty of Candour. They did not direct me to the industry regulator. Instead, I was advised that this case was being reviewed by their ‘customer complaint process’ and I was sent a ‘customer charter’. Their process gave the pharmacy a 20-day cushion for them to thoroughly investigate the error and in this time they batted away my questions and queries.

Their own internal investigation found nothing untoward apart from the terrible human error of a lady behind the counter who served me as the  pharmacist refused (against company and industry guidelines) to come out herself to see if my request for the emergency medication had merit or not.

I made a complaint to the General Pharmaceutical Council (GPhC) and they found sufficient evidence to open an investigation. 

A pharmacy executive was unhappy about this and made efforts to assure the GPhC that this was a simple case of human error despite knowing that this was in fact more than a simple case of human error. The pharmacy executive went on to convince the GPhC investigators that they did not need to question the pharmacy staff that they had identified to take statements from, and, instead, this ‘non-involved’ executive became the single witness representing everyone.

The insurers

I was witness to the harmful influence of insurers, who indemnify healthcare professionals causing them to question their actions in an error circumstance.

When the pharmacy company introduced me to their indemnity insurer, I conducted an internet search and found a piece of advice to their pharmacist members on the National Pharmacy Association website on how to react in a dispensing error circumstance.  In my opinion this advice was written by a legal executive and I suggest it is an invitation to their members to breach their professional duties to their patient.

When I discovered this, I advised the pharmacy company that their branch team had followed this advice almost to the letter. This triggered unseemly actions by both the pharmacy and the insurer. I had many exchanges with them in which I invited them to remove this terrible advice from their website, but was told this is typical advice, and of course it is, but this comes in the form of ‘deny liability’ and represents a threat to all NHS patients.  The National Pharmacy Association did eventually removed this when the Chief Pharmaceutical Officer for England at the time became involved.

I was unable to convince the GPhC that their investigation was corrupted and, therefore, invalidated.

The regulator

The GPhC took 18 months to take statements from the pharmacy executive and myself, consider the factors and make their decision. I called their investigation ‘a parody’.

I was beside myself with astonishment and despair to see that they did not include the breaches in the Duty of Candour in their investigation.

I received an unsigned letter from the ‘outsourced’ solicitor company investigators. I was advised that they had found the pharmacy company to have acted positively to the error and that there were no grounds for further action.

I wrote a strong letter of discontent, in which I reminded the CEO of the regulator that he was a signatory to the joint statement on the Duty of Candour in 2014. To his credit, he commissioned an outsourced review of the handling of the case.

Unfortunately for the cause of finding the truth, learning lessons and doing the right thing, this review was poor. There were aspects of the review that the CEO did not agree with and he ordered that the case should be reviewed again. Seven months of ‘investigations' later, it came to the same conclusions as the first investigation, albeit with a more wordy outcome letter.

Janice and I, as the ‘public being protected’ by this regulator, had been failed on a monumental scale.

Putting patients in harm's way

I have looked behind these fine words and promises to protect the public to find a different set of interests being placed before the public.

I have seen the betrayal, not just of the GPhC but also of other regulators.

I have seen the flaws in the authority tasked with overseeing these healthcare regulators and I have seen the depth of failure.

I was forced by the GPhC to use the Freedom of Information Act to learn otherwise undisclosed details of my case. I found this Act a crucial mechanism as I was able to ask questions of the regulators.

I have used the Act to ask the same questions to NHS Trusts and I have compared the results to see how much safer the public are when they are being cared for by the NHS. That is to say, if an error occurs and this happens within a facility operated by the NHS, are there are better systems in place.

I am very fearful to see community services operating from NHS facilities. I see this as exposing patients to harm. I am committed to seeing changes introduced that will see the public made as safe as it is possible to be.

Difficult questions asked

I finish this story with the difficult questions I have asked. All of these queries resulting from one case.

1. Why is it possible for two healthcare professionals working in the same NHS facility to be regulated differently when it comes to the Duty of Candour? For example, a nurse working in the NHS facility will be regulated by the Nurses and Midwives Council (NMC) and thus governed by the professional Duty of Candour. If a nurse breaches the Duty of Candour they will be investigated by the NMC and the Care Quality Commission (CQC) will be responsible for investigating the NHS facility as the organisation is responsible for its staff to adhere to the Duty of Candour. However, community pharmacies operating within the NHS facility are not regulated in the same way. The GPhC (and other regulators) are not mandated to ask whether the pharmacist under investigation was supported or trained by their employers.
2. Why are there better systems in place for patients when their NHS services are provided by the NHS rather than by a private company? In the NHS the employers have a marked responsibility to ensure that their staff are updated, informed and observe their professional duties. This is because the CQC are policing a statutory duty and a breach in this duty is a breach in law.
3. Why aren’t private companies providing NHS services, such as pharmacies, required to meet NHS standards?
4. Why aren’t private companies regulated for the part of their business which provides NHS services to NHS patients?
5. Why aren’t standard operational procedures standardised across the private companies providing NHS services to NHS patients?
6. When ‘something goes wrong’ with an NHS patient receiving an NHS service from the private sector, why is it the NHS picks up the costs of ‘harm done’?
7. Why are insurers allowed to undermine the integrity of professionals in the conduct of their duties? It is inevitable that when an error has occurred, a professional's thoughts turn to the possible impact on their future, and so it is not surprising that a call to an insurer is made before following employer standard operating procedures and professional guides. In our case, the GP failed to alert the coroner of the dispensing error and only did so following a call to his indemnity insurer.
8.  Why are unregistered professionals working in healthcare exempt from sanction?
9. Why are regulators allowed to make false claims of ensuring public safety?

Janice Payne needs to be the last NHS patient failed by needless neglect. We need to act now in the name of public safety. 

Further reading on the hub:

• How to make a complaint
• How do I make a complaint: Sources of help and advice