A pharmacist’s complete failure to engage with the regulatory process after the consequences of a labelling error has led to the cancellation of her registration
A Melbourne pharmacist has been reprimanded and her licence cancelled, effective early next month.
At a hearing before the Victorian Civil and Administrative Tribunal, Deputy President Heather Lambrick observed that “It is unfortunate to see a young member of the profession place herself in this situation”.
The pharmacist had been registered since early 2015 and in June 2018, was employed as a pharmacist in charge at a Melbourne Chemist Warehouse, the Tribunal heard.
In June 2018, AHPRA was notified regarding her dispensing medication “well in excess of safe limits”.
This initial conduct was “serious,” the Tribunal heard.
The Tribunal noted that the “Committee raised concerns that the dosage was 100 times that of the prescribed dosage and noted that practitioners must be vigilant in ensuring additional care is exercised in dispensing opioid dosages/analgesics with opioid-like activity and paediatric dosages”.
The pharmacist’s dispensing practice raised questions of public risk, it heard.
She had acknowledged a labelling error of 10mL instead of 10mg, explaining the error on “interruptions during the dispensing process”.
The Pharmacy Board took action and conditions were placed on the pharmacist’s registration: that she find an approved mentor and complete three mentoring sessions.
These were to cover complying with the Board’s Guidelines for dispensing medicines and all other applicable practice standards for registered pharmacists; paediatric dosages; and opioid dosages/analgesics with opioid-like activity.
The pharmacist was notified of these conditions.
But after that, she failed to provide the Board with information about where she was practising as required, and between 25 February 2019 and 1 October 2020, failed to comply with the conditions on her registration.
“During this period there were no less than 18 notifications from the Board in relation to these matters,” the Tribunal noted.
The pharmacist ignored them all.
The Board alleged that she had “contravened the conditions to which her registration as a pharmacist was subject,” in failing to nominate a mentor in the required time frame.
She did name a proposed mentor by email, but after this suggestion was knocked back due to the suggested mentor’s relative newness to the profession, failed to provide another name.
AHPRA continued to try and contact her to receive another nomination, and when there was no response by 25 September 2019, told her it proposed to caution her.
Again, there was no response.
When the matter was referred to the Tribunal in October 2020, the pharmacist again failed to engage with the regulatory process.
She did not appear at a February 2021 directions hearing, and failed to get in touch later as to whether she intended to participate in proceedings, including after being personally served with relevant materials.
In February she was contacted by a legal representative, and told them that she did not want to participate in the proceeding.
The hearing took place in her absence.
The Tribunal noted that the conditions placed on the pharmacist’s registration due to the initial error had not been onerous, but were instead a “sensible” way to address regulators’ concerns.
“It was not for her to unilaterally disregard the requirement of the regulator and continue to practise in defiance of the conditions placed on her registration,” it said.
“A practitioner cannot choose to disregard her professional obligations. Nor can she pick and choose which conditions she will or will not adhere to.”
It noted that when a practitioner fails to engage with the regulatory process, there is no way for regulators to see whether they have any insight into their shortcomings, or have taken any steps to remedy them.
“We have no idea and can only speculate as to why [the pharmacist] has so completely disengaged.”
The pharmacist was found to have engaged in professional misconduct and her registration cancelled, as the Tribunal had earlier warned was likely.
While it could have suspended the pharmacist’s registration, the Tribunal noted that to do so would assume suitability to practice after the suspension period was up – but given her lack of engagement, it had no way of knowing that the pharmacist would gain insight and comply with her obligations.
“In circumstances wherein [she] did not comply with the conditions placed on her registration and has given no reason for failing to do so, there would be no point in re-imposing conditions on her registration.
“We can only presume that the imposition of further conditions would again not be complied with.”
The pharmacist must reapply for registration if she wishes to practise pharmacy again.
If the pharmacist “does not reflect on her conduct and learn through such a sanction, she never will,” the Tribunal said.