Double-dosing a ‘contributory factor’ in death of grandfather after medication mix-up
A grandfather died after he took twice as much medication as he should have following a “communication breakdown” between two branches of Boots, a coroner has said.
The fact Richard Lee, 84, took double doses of the drugs he was taking was a “contributing factor” in his death after he collapsed at his home in Norton, Doncaster, assistant coroner Louise Slater told an inquest in the South Yorkshire town.
The hearing heard how Mr Lee was given two sets of drugs by two different branches of Boots in the Doncaster area after a communication mix-up, after which he took double doses for a week.
Mrs Slater told Doncaster Coroner’s Court that seven of the 13 drugs Mr Lee was taking would have had an effect on his blood pressure or heart rhythm.
The coroner said that the individual drugs would have “remained within the therapeutic dose” even if taken at double the prescribed level but she found there would have been an “accumulative effect, especially in a gentleman with underlying severe cardiac disease”.
Mrs Slater said she found that the excess dosing would have increased the risk of a cardiac event and “therefore, I have included this as a contributory factor in Mr Lee’s medical cause of death”.
Mr Lee’s daughter, Gail Pickles, told the inquest last week how a Boots pharmacy in Askern, Doncaster, had agreed to supply his medication through Medisure packs, which simplified his dosing regime, but this branch was suddenly unable to process the prescription and handed responsibility to another Boots pharmacy on Frenchgate in Doncaster town centre.
A short while later the handling of the medication was transferred to a third Boots pharmacy, which was attached to the Askern Medical Practice, where Mr Lee was a patient.
Mrs Slater told the inquest on Friday: “I find that shortfalls in communication between two pharmacy teams at different branches of the same company resulted in a lack of clarity as to which pharmacy would assume responsibility.”
She said there had been a “communication breakdown” over the transfer of responsibility for Mr Lee’s prescription.
The coroner said: “I’m satisfied that policies and procedures were in place at the pharmacies.
“However, they were not followed on this occasion due an individual failing rather than a systemic failure.”
Mrs Pickles told the coroner how her “quiet and reserved” father died at Doncaster Royal Infirmary, holding her hand.
Speaking after the inquest concluded, Mrs Pickles said: “Still, to this day, no one from Boots has ever apologised to me for the error or my father’s death and I am devastated to see that no one from Boots attended today when the coroner handed down her findings and conclusions.
“I have repeatedly, over the past 18 months, written to Boots asking for them to review how they treat families of patients who have been harmed or, like in my case, where there has been a death – I have yet to receive a positive response from them.”
Earlier this year a BBC Inside Out documentary investigated alleged workplace pressures in Boots pharmacists as it examined the the deaths of three people.
After the programme the General Pharmaceutical Council said it had looked into concerns raised with Boots and concluded that “there was not sufficient evidence overall to suggest a risk to patient safety across the organisation”.
Following Mr Lee’s inquest, a Boots UK spokesman passed on their condolences to his family and said: “Making sure that our patients are provided with the correct medication to support their care and welfare is at the heart of everything we do, so when this isolated incident took place in 2016, a thorough investigation was undertaken to understand what happened.
“Following this, we have made our pharmacists aware of the circumstances to make sure we do all we can to prevent a similar incident happening again in the future.”
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