Coroner demands sweeping changes following grandmother's inquest

Published 4 Mar 2010 13:42

A coroner demanded sweeping changes to the drugs industry today (Thurs) after hearing how a grandmother was given the wrong pills by a chemist at a Tesco store.

Elizabeth Lee, a locum pharmacist, gave 72-year-old Carmel Sheller beta-blockers instead of the anti-biotics and steroids which her doctor had prescribed.

Lee, who was given a suspended prison sentence for the error, was working a 10-hour shift during which she did not take a break, when she made the mistake.

She apparently failed to double-check the medication with another member of staff to see if it was correct while she worked in the busy Tesco pharmacy at the supermarket sotre in Dedworth Road, Windsor.

However, a post-mortem examination showed only trace amounts of Propanolol remained in the lung cancer-sufferer's system when she died, three days after she collapsed at home in Windsor and was not responsible for her death.

Making recommendations to health watchdogs and the Royal Pharmaceutical Society(RPS), Berkshire Coroner Peter Bedford said: "There needs to be a requirement for all dispensed medication to be double-checked before it leaves the pharmacy.There should also be a requirement that a patient has a clear written note of medication they are prescribed.At the moment, they hand in their prescription and the public needs to be educated on the requirement to double-check that their medication is correct by looking at the label on the box."

Mr Bedford said he would report to the RPS, the Department of Health, the National Patients Saftey Agency and the Medications and Healthcare Regulation Agency in light of evidence into Mrs Sheller's death heard during the three-day hearing at Windsor Guildhall.

He said drug boxes also needed to be clearly labelled with the generic name of medication in the same place and a colour-coding scheme for the most popular potentially-damaging pills, regardless of what company manufactured them.

Recording a narrative verdict into Mrs Sheller's death on September 2 2007, the coroner said: "Whilst the overdose of Propanolol precipitated Mrs Sheller's admission to hospital on August 30 2007 with low blood pressure and a slow heart beat in addition to her underlying problems, she responded well to her treatment and the main diagnosis remained consistent with the condition for which the original prescription was given.

"On the balance of probabilities, Mrs Sheller died from exacerbation of her underlying natural disease.Any effect of the Propanolol was likely to been so minimal at the time of her death as to be able to be discounted as having any material affect."

For a story on the hearing see tomorrow's Royal Borough Observer.

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