Boots drug death blunder blamed on 'very busy' day
A blind pensioner died after a Boots pharmacy sent him the wrong medication because it had been a "very busy" day, an inquest has been told.
Douglas Lamond, 86, died in May 2012, two days after a pack of drugs was delivered to his home from a Boots branch in Orwell Road, Felixstowe.
He received drugs intended for someone else and not the ones he needed following a mix-up of labels.
A Boots pharmacy worker said staff were under pressure as it was "very busy".
Widower Mr Lamond lived alone at his home in Stuart Close, Felixstowe, and was "almost totally reliant on health professionals" preparing his medication for him as he was registered blind, Det Supt Andrew Smith told the inquest at Suffolk Coroner's Court earlier this week.
The RAF veteran received weekly boxes from the pharmacy.
However, the medication he took delivery of on 10 May contained several drugs labelled with a different name.
Boots dispenser Susan Hazelwood told the inquest she had made an error on a day when the pharmacy was particularly stretched.
She said she needed to add a new drug to Mr Lamond's box, but accidentally picked up another patient's box instead.
She slit it open then resealed it with sticky tape.
The practice was against standard procedures, but Ms Hazelwood said she did not know this at the time, and that it was the responsibility of the pharmacist to check the box before it was sent out.
She told the inquest that although she would usually look inside the boxes herself to double-check labels, on this occasion she "didn't know" if she had found time later to do so.
"We were very busy, we were doing a nursing home at the time and other boxes, and I had to wait a couple of hours before I had time to sort it out," Ms Hazelwood said.
The pharmacist responsible for checking the pills, Mihaela Seceleanu, admitted she may not have checked the entire box, and said: "I will forever regret this mistake."
The inquest heard Mr Lamond was wrongly given the anti-diabetic drug Gliclazide, which is used to lower blood sugar levels, and did not receive his usual Bisoprolol, a beta-blocker used to treat high blood pressure.
Mr Lamond died from heart failure on 12 May at Ipswich Hospital.
Clinical pharmacologist Robin Ferner told the inquest the drugs mix-up had placed the "frail" pensioner at greater risk of suffering a heart attack.
Recording a narrative verdict, Suffolk Coroner Dr Peter Dean, said Mr Lamond died from the combined effects of his serious pre-existing medical conditions and the consequences of "a very significant accidental dispensing error which resulted in him receiving another patient's medication".
Following the conclusion, Mr Lamond's daughter Dianne Moore said in a statement: "I am glad to finally have the circumstances of my father's tragic and traumatic death in the open.
"We would not wish any other family to go through such a devastating experience."
He was a "kind, thoughtful endearing man, a real gentleman", she added.
Dr Jose Moss, deputy superintendent pharmacist for Boots UK, said an investigation found that shortfalls had resulted from human error, and that standard operating procedures in place had not been followed.
A Boots UK spokesman apologised for the "tragic error" and said the company had "shared the learnings from this incident to help prevent this happening in the future".