Failure to question GP leads to reprimand

doctor makes "stop" gesture with hand - ama

A Sydney pharmacist proprietor has been reprimanded after failing to challenge a GP over prescribing of addictive drugs that saw a woman overdose

The co-proprietor of a pharmacy in Sydney’s eastern suburbs has been reprimanded and ordered to undergo mentoring after dispensing high doses of fentanyl and morphine to a longstanding patient of the pharmacy without questioning the prescriber.

Dispensing issues were discovered after the patient was found by police having overdosed with the intent to end her life in October 2017.

Police subsequently seized large amounts of Schedule 8 medications from her home, including morphine injections, fentanyl patches and oxycodone capsules.

The pharmacist had been a co-proprietor of the pharmacy since September 2015. He was the only proprietor who regularly worked in the pharmacy and was responsible for day-to-day activities.

Between September 2015 and October 2017, the proprietor or his employed pharmacists dispensed prescriptions for morphine ampoules to the patient in combination with scripts for oxycodone and fentanyl.

During the same period, they also dispensed to the patient scripts for bromazepam and temazepam, which the Health Care Complaints Commission (HCCC) complained placed her at risk of excessive sedation and respiratory depression.

A Pharmaceutical Regulatory Unit (PRU) analysis found that from 2016 to 2017, the patient was dispensed 2,300 morphine 30mg ampoules and 160 Durogesic (fentanyl) 100mcg patches.

This amounted to an average apparent dose of 4.78 morphine injections per day and an average dose of 0.54 fentanyl patches per day, representing an Oral Morphine Equivalent Daily Dose (OMEDD) of up to 931.65mg.

Within the first week of becoming the proprietor of the pharmacy, the pharmacist said he reviewed the patient’s dispensing history and called her GP to confirm her medication.

He recalled making three phone calls to the GP about the patient, however only one of these calls was reflected in writing.

Information provided by the pharmacist to the PRU showed that there had been one clinical intervention by him with the patient’s prescribing GP on 18 December 2015 regarding the “potential overuse” of morphine.

The pharmacist stated that during his conversations with the GP, the GP was “adamant” about the patient’s treatment plan, which included a specialist and in-house carers.

This, along with the fact that the GP had been looking after the patient for many years and visited her at home regularly, resulted in the pharmacist feeling it was not his place to question the GP.

The pharmacist also stated that his lack of experience as a pharmacy proprietor and his lack of knowledge in chronic pain management prevented him from questioning the GP’s decision.

However an expert witness told the NSW Civil and Administrative Tribunal that the standard expected was to ensure that any dispensed medication which appeared to be a higher-than-usual dose was carefully investigated to ensure the pharmacist felt confident the prescription and medication were appropriate and for a therapeutic use.

The pharmacist acknowledged that he should have requested written documentation from the GP and called Pharmaceutical Services for advice regarding the patient’s prescribed dose before dispensing.

He recalled his employee pharmacists mentioning that they spoke to the GP and confirmed the need to continue the morphine, but he was unable to recall which employee pharmacist did so. He also stated that he did not record visits, conversations and observations in relation to interactions with the patient.

Evidence revealed that apart from the conversations the pharmacist had with the GP in late 2015, no further interventions were made by the pharmacist in relation to the patient’s treatment from December 2015 until to her attempted suicide in October 2017.

On learning that the patient had tried to take her life and been hospitalised, the pharmacist stated that he was “devastated”.

Any disciplinary proceedings against the prescribing doctor have not yet been made public, however AJP notes that he is no longer registered with Ahpra and the PRU had commenced an investigation into his prescribing for the patient.

During disciplinary proceedings, the Tribunal highlighted the important role of the pharmacist, pointing to the requirement to exercise independent judgment in dispensing medicines.

“Pharmacists have legislative and professional responsibilities to assess whether it is safe and appropriate to dispense a prescription. They should not merely assume that when a prescription is presented that all is well,” it said.

“A pharmacist should possess the judgment and skill to question where prescribing patterns raise suspicions and to seek further advice or counsel.

If there was no role for the pharmacist in this regard, then doctors would be dispensers as well as prescribers.

It found that given the quantity, frequency and combination of medication dispensed by the pharmacy, the pharmacist’s failure to take steps to address the patient’s medications in both his capacity as proprietor and dispensing pharmacist placed her health and safety at significant risk, which “was ultimately realised by [the patient’s] hospital admission for a drug overdose”.

The Tribunal found that the pharmacist’s conduct was of a sufficiently serious nature amounting to professional misconduct.

However it noted that that there were no other deficiencies in the pharmacist’s general clinical practice apart from the care he provided to this singular patient.

The Tribunal found that he presented as genuinely remorseful and did not seek to avoid responsibility or minimise the seriousness of his involvement. He had also undertaken further education in ethics and dispensing.

“In our view, [he] as a new pharmacy owner was working in a situation possibly beyond his ability to cope and without adequate collegial support,” it said.

“When he saw photos of the amount of medication [the patient] had in her possession he was shocked and speechless. He said [the patient’s] overdose had a profound impact on him because he had chosen the profession of pharmacy to help people.”

While the HCCC sought an order of suspension, the Tribunal was satisfied that the pharmacist “is unlikely to repeat his errors” and suspension of registration was not warranted.

The pharmacist was reprimanded and ordered to undergo mentoring for a minimum of 12 months, with a particular focus on the dispensing of Schedule 4B, 4D and 8 medications.

He was also ordered to pay costs to the HCCC.

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  1. Alvin Siaw

    So, I’d like to know what happened to the GP? Can the author please inform? I sincerely hope that the GP had a more severe punishment than what the pharmacist got.

    • Sheshtyn Paola

      Hi Alvin,
      Thanks for your comment. I actually included a line on this in the article but you may have missed it (fair enough, it is a long article).
      Any disciplinary proceedings against the prescribing doctor have not yet been made public, however AJP notes that he is no longer registered with Ahpra and the PRU had commenced an investigation into his prescribing for the patient.
      Kindest regards,
      Sheshtyn Paola (author, AJP)

      • Alvin Siaw

        Thank you for clarifying that Sheshtyn! It’s good to know the fuller context of the outcome to everyone involved. I understand the article is predominantly for pharmacist audiences, hence the focus , and potentially could sound like the onus is only on the pharmacist. Thank you again !

  2. Tony Lee

    Sad but there is no reasonable defense

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