A pensioner could have been given the wrong drugs because staff at her local pharmacy knew her so well they bypassed their own safeguards.
Margaret Forrest was given powerful diabetes tablets by a Highland branch of Boots – because her surname was similar to that of the intended patient Florence Frost.
The 86-year-old, of Kingussie, suffered a hypoglacaemic brain injury and died just a few days later.
At a fatal accident inquiry yesterday, employees of the local Boots branch admitted they did not always follow their own safety procedures when they knew the patient.
Inverness Sheriff Court also heard that shortcuts were taken if staff were too busy or tired.
The shop was also short-staffed at the time because two workers were absent – one off sick and one on honeymoon.
Fiercely independent widow Mrs Forrest, who lived in a flat above the family-run gift shop in the village, lapsed into a coma after taking Gliclazide, a drug intended for diabetic sufferer Mrs Frost. She was found unconscious by her son Billy.
During the second day of the hearing yesterday, it emerged both women’s medication was on the same shelf and that an unknown member of staff had given Mrs Forrest a tablet box marked for Mrs Frost, despite it being a different size.
Fiscal depute Alasdair Macdonald suggested to Boots dispenser Joan Harrison: “Maybe what has happened here is that familiarity of the patient meant that it was handed out without ensuring the signing act?”
The 64-year-old replied: “Possibly.”
Mrs Forrest’s son Steven is representing the family for the inquiry.
He asked Mrs Harrison: “When my mum got the wrong box, it could have happened because the shop was short-staffed and you were tired?”
Mrs Harrison replied: “Yes.”
Mrs Harrison told the court Mrs Forrest had gone on to a new dispensing system called Medisure about two weeks before the tragedy.
She said: “This is where tablets on repeat prescription are put in a weekly box to aid the patient to remember what they have taken and when by placing the tablets in separate compartments.”
Mrs Harrison said she couldn’t remember if she had given Mrs Forrest the box intended for Mrs Frost.
She added: “Patients and staff are supposed to sign a diary when they collect their box, but on this occasion it had not been done. That was something Nicola Ferguson (the manager) brought in and it has now been extended store wide.
“I can’t explain how she ended up with Mrs Frost’s pack. I can’t remember if it was me but anyone could have done it that day. Things are different now.”
Dispensing assistant Eva Oden told the inquiry: “I remember Mrs Forrest coming in. She was a memorable woman and quite a character. She was waving her empty box around wanting it refilled.
“The shop was quite busy and she was in for about five minutes. She gave it to Nicola Ferguson but I don’t know if Nicola gave her the new one.”
The inquiry also heard that procedures had been reviewed since Mrs Forrest’s death on November 15, 2013 and more rigorous checks now had to be made with patients collecting prescriptions.
An informal signing of a dispensing diary has now been made mandatory, and medication for patients with similar names had to be clearly marked and kept separate, rather on the same shelf.
All pharmacy staff have been told they will not be prosecuted by the Crown or the family.
The inquiry, before Sheriff Margaret Neilson, continues.
