FAI finds ‘human error’ caused death of woman given wrong medication by pharmacy

Margaret Forrest, 86, contracted bronchopneumonia and suffered cardiac amyloidosis as a result of the consumption of diabetes tablets meant for another patient, which were given to her in error by a member of staff at her local branch of Boots the chemist, a fatal accident inquiry found.

Sheriff Margaret Neilson held that while there was “no defect” in Boots’ system of working which contributed to Mrs Forrest’s death, the accident would not have occurred if the pharmacy’s standard procedures had been properly followed.

The FAI, which was held at Inverness Sheriff Court earlier this year, heard that the incident happened at a Boots store in Mrs Forrest’s home town of Kingussie in November 2013.

Mrs Forrest, who resided alone in a flat above her family’s gift shop on Kingussie High Street, lived independently and was in generally “good health” with the exception of some age related conditions for which she was prescribed a number of different medications.

She enjoyed travelling and had continued to do this into her 70s and 80s, and was able to travel independently on the bus, clean her own flat and generally look after herself.

However, she had become confused about her medication and on around 1 October 2013 her GP decided that it would be helpful for her to receive her medication in a “dosette box”– sometimes branded as a Medisure pack – a packaging system where tablets are removed from the manufacturers’ original packaging and repackaged.

She attended the pharmacy and uplifted her Medisure packs on Thursday 24 October and the following Thursday, and on both occasions she required to sign a “domiciliary dosage system” (DDS) book.

But when she returned on Thursday 7 November she was wrongly handed a Medisure pack meant for another customer of the pharmacy, Mrs Florence Frost, and was not asked to sign the DDS book.

Having not heard from his mother for a few days, Mrs Forrest’s son William went to her flat on Tuesday 12 November.

On entering the property he found her collapsed and unconscious in the hallway and paramedics were called.

She was taken to Raigmore Hospital in Inverness but never regained consciousness and died two days later.

Sheriff Neilson found that it was “impossible to determine” who had handed the incorrect medication to Mrs Forrest but said it must have been one of the staff at Boots on the day in question.

She noted that Boots UK Limited had standard operating procedures for a number of processes, including Standard Operating Procedure 006, Version 5 which related to the dispensing of medication.

The sheriff found that had process steps 1 to 4 of this procedure been observed and followed, Mrs Forrest would not have been handed the medication meant for another customer of the pharmacy.

She also noted that Boots UK Limited were the defenders in a personal injury action raised in the Court of Session by various members of the deceased’s family, in which the company admitted being “vicariously liable” for the negligence of one of their members of staff in handing the wrong Medisure pack to Mrs Forrest.

In a written determination, Sheriff Neilson said: “The medication dispensed into the two Medisure packs meant for Mrs Forrest and Mrs Frost was correctly dispensed, labelled, checked and bagged. The error was not at the dispensing stage but at the handover stage.

“In conclusion, it appears that tragically Mrs Forrest was handed the wrong Medisure pack by an employee of Boots UK Limited in Boots pharmacy, High Street, Kingussie. This clearly should not have happened.”

Had the pharmacy’s standard operating procedures been correctly followed, “this would not have happened and the accident and consequent death would not have taken place”.

She added: “It seems that the accident was as a result of human error, an error which has had tragic and catastrophic consequences.”

Boots UK Limited have apologised publicly for the error and since the accident all members of staff at the pharmacy including the pharmacist underwent refresher training on the company’s relevant Standard Operating Procedures.