Sons receive "unreserved" apology after mother dies from medication mix-up
The sons of an 86 year old backpacking pensioner received an "unreserved" public apology for the first time yesterday from Boots, almost two and a half years after their mother died from taking the wrong medication.
The sons of an 86 year old backpacking pensioner received an "unreserved" public apology for the first time yesterday from Boots, almost two and a half years after their mother died from taking the wrong medication.
The company's deputy superintendent pharmacist Dr Josie Moss said 'sorry' on the third day of a fatal accident inquiry into the death of Margaret Forrest from Kingussie.
She had been given tablets which should have been handed out to another woman suffering from diabetes. Mrs Forrest died on two days after November 14 after being in a coma brought on by her consumption of six Gliclazide tablets in a three day period in November, 2013.
But Dr Moss told the inquiry that no changes had been made to the company's standard operating procedures (SOP) 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.
"If we constantly change things then we are adding complexity and that does not add additional safety. It may have the contrary effect and there is more possibility of human error and to forget things." Dr Moss went on.
She added: "If we had more coloured boxes for instance to indicate dangerous medicines, there would be more confusion. There are a lot of similar drugs out there."
Mrs Forrest, who had been backpacking around the world, even 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.
Her tablets were placed by the Kingussie branch of Boots into a monitored dosage box which she collected weekly.
But Mrs Forrest picked up a box which was lying next to hers and should have been delivered to a Florence Frost, who was diabetic. It was the drug Mrs Frost should have been given which killed Mrs Forrest.
Her son, Steven observed: "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.
The inquiry is expected to finish today (Thursday) with submissions from the various parties represented and Sheriff Neilson will issue her determination, findings and any recommendations at a later date.