A pharmacist’s registration has been cancelled for two years after 50 forged scripts were dispensed and the equivalent of a box a day of diazepam a day went missing at his pharmacy
The NSW Civil and Administrative Tribunal heard that after receiving information from the police in April 2016, the Pharmaceutical Regulatory Unit (PRU) began an investigation into the pharmacist and one of his two Sydney stores.
The alleged breaches in question concerned dispensing of more than 50 forged prescriptions for S8 opioids, mostly in higher strengths, to a number of patients and took place from January 2014 to July 2016.
More breaches were alleged regarding the supply of several S8 and S4D medicines at intervals which exceeded the prescribed dose; and the shortfall of almost 35,000 tablets of diazepam 5mg and several unaccounted S8 drugs, which was identified at the time of the PRU audit.
These opioids included 140 MS Contin 100mg tablets and three 200ml bottles of Ordine strength10mg/ml.
The practitioner was the dispensing pharmacist on some of the relevant occasions, but on most occasions was conducted by his employee pharmacists.
In October 2016 the Pharmacy Council of NSW held s150 proceedings and in November, it imposed conditions on the pharmacist’s registration, including that he not practise as a pharmacist.
The pharmacist admitted to most of the alleged behaviour prior to the hearing, and on the morning of the hearing also admitted to the rest.
The Tribunal heard from a peer expert who explained that while the pharmacy owner had not been involved in most of the dispensing in question, as an owner he would have been expected to “vigilantly maintain an active interest in how the practice of pharmacy is being conducted” as per the relevant Guidelines.
The expert, Dr Betty Chaar, expressed strong criticism about the dispensing of S8 (and in one case, S4 and S4D) medicines at short intervals, which meant the patient was receiving medication in excess of the prescribed dose.
She also criticised the “failure of oversight and professional judgement” around the length of time some patients had been receiving high-strength opioids.
The Tribunal heard that the pharmacy owner had failed to make contact with prescribing doctors to assess the validity of the forged scripts and instead relying on the fact that the patient was known to the pharmacy. However one patient was not actually known to the pharmacy before they brought in one of these scripts, and instead the pharmacy simply received a phone call purporting to be from the prescriber.
“In numerous other instances the pharmacist undertaking subsequent dispensing assumed that the pharmacist who had first received a Sch 8 script from that patient had undertaken the appropriate checks,” it noted.
While the pharmacy owner claimed that this was not common practice at the pharmacy, the Tribunal did not accept this, saying that such failures were “systemic in the sense that for a number of the patients multiple pharmacists did not personally make the proper checks before dispensing Sch 8 medications”.
Dr Chaar’s expert opinion was that there were many indications of forged scripts in the evidence provided.
“There were erratic and seriously close intervals for example that would have triggered alarm bells for most pharmacists and a prompt to investigate,” the Tribunal noted.
“Pharmacists should not dispense blindly, even though they might consider themselves familiar with the prescriber’s handwriting or prescribing habits.
“It is almost unthinkable to consider dispensing such [high strength, short interval] prescriptions without proper and documented investigation.”
The Tribunal accepted Dr Chaar’s evidence and noted that the pharmacy owner “had direct knowledge of the high strength and increasing volume of Sch 8 medication being dispensed by the pharmacy at the relevant time”.
“The practitioner’s failure to ensure that the dispensing of every Sch 8 script was in adherence to the requirement that the dispenser be familiar with the doctor or patient, both in his own dispensing and that of his employees, was very serious.”
It noted that despite his own evidence that he had put in a third S8 drug safe to cope with the demand for opioids in 2016, and issuing an average of seven S8 scripts a day, the pharmacy owner had not been alert, or ensured his employees were alert, to risk factors for opioid misuse and fraud.
These factors included private scripts for PBS medications, high volume and high strength opioids, and inappropriately short intervals between supply.
In the case of one patient, the person was given five boxes of 25 Durogesic 100mcg patches on a private script.
“Such patches are prescribed for use over a three day period, so this was a 75 day supply of a high strength opioid,” the Tribunal noted.
“One fentanyl 100mcg transdermal patch applied every three days is the equivalent of 300mg of morphine orally daily. Approximately 60 days later Patient C was again supplied by the pharmacy with another 25 patches.”
The last supply to this patient, the Tribunal noted, was several weeks after the PRU had visited the pharmacy and seized the S8 register.
As such “the practitioner was well and truly on notice” that issues had been identified with the way the pharmacy was managing S8s.
Another patient was being medicated for a schizoaffective disorder and had informed the pharmacy owner that he was taking eight to 10 tablets of paracetamol 500mg/codeine 30mg a day and between five and nine tablets of diazepam a day.
“While the practitioner claimed to have counselled the patient in relation to the risk of damage to his liver from the paracetamol he produced no file notes or documentary evidence of these discussions; nor, he conceded, did he ever raise the risks of codeine dependence with the patient,” the Tribunal noted.
The pharmacy owner could not recall what malady the Panadeine Forte had been prescribed to treat.
According to the pharmacy’s records, between January 2014 and November 2016 the pharmacy supplied this patient with 4,550 diazepam and 8,400 Panadeine Forte.
Panadeine Forte was dispensed in amounts of up to 240 tablets at a time, and diazepam up to 150 tablets at a time. The owner was the dispensing pharmacist on a number of these occasions, but never contacted the prescribing doctor.
In his written statement, the owner said that due to this patient’s inability to self-manage, and to protect their health as well as to prevent the staff being harassed, he decided to “stagger” supply.
He clarified that this process “involved dispensing the medication on the script and then bagging it in smaller quantities which were held at the dispensary counter and provided by ‘the girls’ [the employee pharmacists]” to the patient over “some time,” the Tribunal noted.
He said this decision was undertaken with the employee pharmacists, but the employee pharmacist who gave evidence denied helping make this decision or providing the bagged supply.
The Tribunal found this “staggered” supply of medicine to be “improper and grossly unethical as a practice”.
The pharmacy owner said he did not know where the missing medicines had gone, and had not noticed the disappearance of diazepam because it was of minimal financial value – despite this equating to a loss of around a box a day during the relevant period.
His only suggestion was that it had been thrown out in a RUM bin after accumulating as excess dispensary stock.
“There is no reasonable explanation for how 700 boxes of a Sch 4D drug came to accumulate in the storeroom and yet still continue to be periodically ordered, sometimes five or six times a month,” the Tribunal noted.
The owner insisted that the diazepam had not entered the community and that he had only recently become aware of a black market for Diazepam and MS Contin, a claim the Tribunal had difficulty with given the owner’s 25 years in practice as a pharmacist.
The Tribunal noted that he had sought to minimise his responsibility by painting himself as rarely present in the pharmacy, and that he had fallen back on claims of “naiveté, delegation and distraction” and under cross-examination, referred to himself as a “silly man”.
The Tribunal found his account of his behaviour as “at best woefully inadequate and at worst disingenuous”.
It cancelled his registration for two years and ordered him to pay costs.