The UK’s biggest chemist yesterday apologised to the family of a pensioner who died after a medication mix-up – more than two years after her death.
Margaret Forrest, 86, suffered a catastrophic brain injury after she was given diabetes tablets destined for a patient whose surname started with the same letter.
The blunder happened in a branch of the chemist in Mrs Forrest’s home town of Kingussie in Novermber 2013.
Yesterday, during an FAI at Inverness Sheriff Court, Boots’s deputy superintendent pharmacist Dr Josie Moss said ‘sorry’.
But Dr Moss also told the inquiry that no changes had been made to the company’s standard operating procedures (SOPs) as a result of the tragedy.
She told Sheriff Margaret Neilson: “They have been refreshed and re-emphasised to all our staff in our 2,400 branches across the UK. Packages for patients with similar names have a warning label and there is a requirement to sign a docket. But no changes have been made to our SOPs because it would increase the risk of more errors being made.
“This was caused by human error and not our procedures. If they had been followed it would not have happened. We have a three way security check which is carried out millions of times a day across our branches.
“On this occasion it wasn’t. We are keen to learn from our mistakes and we know human beings come to work and there is a risk that something can go wrong, however good the processes, and there can be tragic consequences.
“Mrs Forrest should have got a pack of nine medicines. But she got a pack of only two. There was a failure to reconcile her name and address with what was on the prescription and what was on the bag.
“I still feel the procedural steps are the right ones and we wouldn’t change them. But we have reinforced to all our staff the importance of not having an over-familiarity with patients and highlighted this case.”
Mrs Forrest, who had been backpacking around the world into her eighties, was put on to a Medisure system of getting her medication only weeks before her death. Her GP was concerned she would take there wrong medicine at the wrong time and ordered the change.
But Mrs Forrest ended up taking Glicazide which should have been delivered to a Florence Frost.
Mrs Forrest’s son Steven said: “It is tragic that what was meant to protect my mother actually killed her. I note Dr Moss’s apology in her investigation report into my mother’s death, but today was the first time we have had an unreserved apology from Boots.”
