Pharmacist Criticized for Mismanagement in Fatal Case

A man died from a brain bleed after a pharmacist failed to consult his general practitioner despite alarming blood test results. The incident, which occurred on September 8, 2021, has drawn significant criticism from the Deputy Health and Disability Commissioner, Carolyn Cooper, highlighting serious lapses in pharmacy protocol.

The patient, referred to as “Mr A,” reported an “extreme” headache and unusual “swishing noises” in his ears but insisted he felt generally well. His condition deteriorated rapidly, leading to his wife calling for an ambulance. Unfortunately, surgery was deemed impossible, and he subsequently passed away. Mr A was taking Warfarin, a blood-thinning medication, which necessitated regular monitoring through INR (International Normalized Ratio) tests.

The investigation revealed that the pharmacist, identified as “Mr B,” neglected his obligation to contact Mr A’s GP when INR results fell outside acceptable limits. Under established protocols, the pharmacist was required to act if the INR readings indicated potential risks. On three occasions, Mr A’s results were concerning, with one reading reaching 5.6—well above the normal range of 1.5 to 4.

Cooper noted that Mr B made independent decisions regarding Mr A’s Warfarin management without consulting the GP, which constituted a breach of his professional responsibilities. She expressed her disapproval of Mr B’s unilateral approach, stating that he should have either secured GP approval or directly communicated with the doctor regarding the treatment plan.

During the investigation, it became evident that the pharmacy used a software system intended to alert GPs about abnormal test results. However, due to an incorrect email address, Mr A’s GP did not receive notifications about the concerning INR levels. Mr B ticked off a box indicating that a “medical review” had taken place, despite no such conversation occurring with the GP.

The situation was complicated further by the pharmacy’s response to Mrs A’s complaints. While she described her interaction with the pharmacy owner, referred to as “Mr C,” as defensive and intimidating, Mr C felt he was attempting to address her concerns empathetically. Cooper highlighted that the lack of a formal apology or acknowledgment of Mrs A’s grievances was concerning, urging the pharmacy to improve its complaint management process.

In response to the incident, the pharmacy initially increased staff training to ensure compliance with INR testing protocols. Nonetheless, as of July 2024, they have discontinued the testing programme altogether. Mr C cited the stress of the investigation and the absence of the involved pharmacist as factors in their decision to halt the service.

The Deputy Commissioner remarked that while she understood Mr C’s decision, it was disappointing for the local community that relied on this service. She also recommended improvements to the software system to ensure better oversight of patient results.

As a result of these findings, Mr B was found to have breached the Code of Health and Disability Services Consumers’ Rights. Should he return to New Zealand and seek to practice again, Cooper advised that the Pharmacy Council of New Zealand consider reviewing his professional competence.

This tragic case raises critical questions about pharmacy practices and the importance of clear communication within healthcare teams. As the health sector continues to adapt, it is crucial that protocols are strictly followed to prevent similar occurrences in the future.