Dose concerns ignored before death

A pharmacist believed the dose of methotrexate prescribed to a man who later died was inappropriate – but her concerns were ignored

Fairfax media outlets have reported on the inquest into the death of 77-year-old Ian Gilbert, who was prescribed methotrexate in 2015 to treat a flareup of psoriasis on his back and legs.

Reporter Aisha Dow writes that when the pharmacist was presented with the script, she became worried that the dose could be lethal, and telephoned the doctor with “extreme concerns”.

The dose was twice daily 2.5mg of methotrexate.

The prescriber told the pharmacist that he did not wish the dose to be changed.

Mr Gilbert, a former real estate agent and father of four, died after being hospitalised and his family says that an autopsy found the cause of death to be complications of methotrexate toxicity.

Through the family’s legal representative, Paula Pulitano from Slater and Gordon, the court heard that Mr Gilbert suffered from a number of chronic illnesses, including a “renal issue”.

The family say he should not have been prescribed the drug, and the pharmacist should not have dispensed it.

Ms Dow writes that the case has “exposed tension” between doctors and pharmacists.

Expert witness Pamela Mathers, a community pharmacist, told the court that she believed a culture existed among prescribers of not always responding to the concerns of pharmacists.

“Some doctors are really awful to deal with,” she said.

“At the end of the day it’s doctors that call the shots.”

However she also said that many doctors were “great to deal with” and always engaged in discussion when contacted.

The inquest is ongoing.

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  1. pagophilus

    Still, she shouldn’t have dispensed it. If you’re not convinced, ask for written evidence of the dose ie a reference of some sort.

    • Karalyn Huxhagen

      As a senior pharmacist I take calls from younger pharmacists often who are faced with similar situations. A current case looks at a young pharmacist in a small town where the GP ceases all medications and recommends alternate therapies for CCF, Diabetes and cancer treatment. Referral to AHPRA has not helped . Where do these pcists go for help?

      • pagophilus

        Not knowing any further details about the case it’s difficult to comment, but there are issues which need addressing. One is cultural – some cultures are hierarchical and disagreeing with or challenging a doctor (who is higher in the pecking order than a pharmacist) can be very uncomfortable or is simply not done. With high-risk drugs eg methotrexate pharmacists must learn to withhold unless there is convincing evidence to give. “Because the doctor wants it” is not enough of a reason.
        Also, not knowing anything more about the case you mentioned, I can’t add too much. However, I believe that sometimes we need to clearly spell out our concerns to the patient even if it contradicts the message they are getting from the doctor. If a cancer patient is toward the end of their life and yet they are having treatments suggested to them (sometimes at great cost to the patient, if they are non-PBS), offering them false hope that they may be cured we need to be prepared to discuss this with patients. If we believe the treatment being given is inappropriate and you can’t get anywhere with the doctor, I don’t see a frank discussion with the patient as being out of line, as long at it is within our scope of practice and in line with the evidence available to us.
        Overall, we all need to grow some balls (myself included) to be able to stand up and say something or to refuse supply.

  2. Kelly Lin

    Pharmacists do record the findings and their encounters with GP on the script if not, they will have a standard protocol adopted in store for the intervention. Date of the conversation, time, Dr name and the result of the intervention is recorded on the script. That is the evidence itself. The pharmacist did not dispense the script blindly, she did pick up the issue and consulted with the prescribing doctor. At the end of the day the doctor did not want to listen to the pharmacist and did not take the advice and insisted that the prescription should be dispensed as it. I feel for the family but I also feel for the pharmacist. Ultimately the Pharmacist exercised her duty of care. Just a pity doctor didn’t.

    • Katie Browne

      I don’t think we can say the Pharmacist exercised her duty of care, when she went ahead with dispensing a medication at a dose she knew was clinically unsafe. She is responsible for her own judgement and actions, and as a pharmacist she knew that dose was extremely unsafe. The choice to dispense was hers, no doctor can force a pharmacist to supply a medication- that is one of our main purposes, to act as a system of checks and balances that ALWAYS puts patient health and safety as the number one priority in all we do. She failed to do so, so yes a portion of the blame is hers. I certainly feel for her, we have all found ourselves between the proverbial “rock and hard place” when it comes to dealing with patients and Doctors. Unfortunately this time the situation ended in the worst outcome possible, and needs to serve as a reminder that we as pharmacists are not simply there to do a Doctor’s bidding, but to utilise our own training and expertise to keep patients safe.

    • Stephen Roberts

      Kelly, a man died from an overdose of a potent drug dispensed by a pharmacist who knew it was an overdose.
      How you can say “the pharmacist exercised her duty of care” is baffling.

  3. Angus Thompson

    This case is tragic and I feel for all involved, but we as pharmacists must ‘hold the line’ when we feel it is appropriate to do so. In my career I have had one occasion where after much discussion, I told a prescriber (consultant) that I was just not happy to dispense a script he had written as I felt it was clinically inappropriate. This resulted in a remarkable ‘about face’ with the prescriber then agreeing to change in line with my recommendations rather than deal with the ‘fallout’ of the patient being told that I would not supply.

  4. kingswaycompounding

    There was a legal case in the UK back in the early 80’s i believe where a pharmacist dispensed Migril (ergotamine) tablets with an incorrect dose as prescribed by the doctor. The judge ruled that effectively both were equally to blame for the injury to the patient. The judge ruled the pharmacist as the last line in the healthcare process should have recognised the dose error and not dispensed the medication. Its not exactly similar to this case but the ultimate take away for all pharmacists back then was don’t dispense a medication if you have any doubts that it is not appropriate for the patient. It was a landmark case that was drilled in to all pharmacists in Uni. You have the right and the legal obligation to protect your patient always and a cranky overworked dr yelling down the phone is no justification to ignore your professional obligations. (most dr.s today are great to deal with in my experience!) You simply refuse to dispense the medication. I really do feel for this pharmacist and we all know its every pharmacists worst nightmare to get ‘that call’ and your body goes into shock mode. As for the patients family its a nightmare too and my condolences. But many pharmacists today are very averse to confrontation and how to deal with confrontation especially in a professional setting. They must stand strong in these situations and be the professional they are trained to be. Perhaps there is a need for further training in this area of pharmacy practice….. at the end of the day its the doctor AND the pharmacist that calls the shots.

  5. Amandarose

    We have had a few similar scripts and the doctor refused to change it so my colleague told the patient not to use it and refused to fill it. They huffed and went elsewhere. He gave the GP written information and discussed it in person. I don’t know the outcome but the patient didn’t die so my guess is he changed the dose.
    Other serious incidents they refused to change ( Like initiating acute pain Treatment in a young person with high dose fentanyl) we have been forceful in arguing against and won with some tension.
    At the end of the day if the dose look bad, there is no evidence of safety DO NOT DISPENSE.
    The buck actually stops with us if we know a drug us not right. If a doctor is stubborn articulate your concerns with the patient and tell them to get another opinion.

  6. PharmOwner

    Whether or not doctors are “nice” to deal with or “difficult” is not really relevant. There were failures on the part of the doctor and the pharmacist. Methotrexate is one of those drugs with a narrow therapeutic index, that I expect all pharmacists would be wary of dispensing. Colchicine, warfarin and digoxin also spring to mind. An ongoing bd MTX dose in a 77 year old with renal issues and comorbidities should be ringing alarm bells. A tragic outcome for all concerned. The only winners in this case will be the lawyers.

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