Penalty too light for pharmacy error that led to woman’s death: granddaughter

HALIFAX — A Nova Scotia woman who watched her grandmother descend into pain and die after receiving five times her weekly prescription says the supervising pharmacist should receive tougher sanctions.

The Nova Scotia College of Pharmacists found pharmacist Alexandra Willson failed last May to make sure 90-year-old Bernice Bond received the proper dosage of methotrexate, a drug that suppresses the immune system.

It was one of two findings of pharmacists’ errors that led to deaths of patients announced this week in the province.

In a decision dated Dec. 19, the college ordered Willson to serve a two-month suspension, pay $12,500 in fines and legal costs and submit to a series of audits, as well as write exams, improve quality assurance programs and apologize to Bond’s family.

However, Bond’s granddaughter Samantha Rumley calls the penalties “lenient,” and adds “two months out of somebody’s life is in hindsight nothing,” and is calling for a removal of Willson’s licence.

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“It was a lot of suffering. … It was a lot of pain for my Nan. The fact we couldn’t console her the way we wanted to on the last two days before her death, it was very disturbing. It wasn’t how anybody should have to pass,” she said. A severe infection prevented family members from touching a woman who had sat by their bedsides whenever they were ill.

Bond died on June 16 at a hospital in Antigonish, several weeks after receiving the medicine and after a series of infections that followed the collapse of her immune system.

The college says Willson’s pharmacy in Canso, N.S., provided Bond with a blister package last May that caused the woman to take seven consecutive doses of the medicine in a single week — totalling 75 milligrams of the immune suppressant medicine — rather than the once-a-week prescription of 15 milligrams she was supposed to take on Wednesdays.

The error was made by a new pharmacy assistant, and initially detected by Willson. The pharmacist instructed her assistant to leave the Wednesday dosage and to remove the 10 milligram and five milligram pills from the other daily blister packs.

However, the assistant only removed the five milligram pills.

The college committee, composed of two pharmacists and one member of the public, found the assistant “did not have sufficient training or experience in preparing compliance packages … and (Willson) did not recheck” the package before the medicine was sent to Bond.

In addition, the findings noted that Willson had misled the college the year before by stating she had implemented a quality assurance program aimed at preventing errors, and that she had not reported a similar error in Bond’s prescription that was detected and corrected a month earlier.

Rumley says her family doesn’t accept the sanctions as sufficient for the pain her grandmother suffered in her final days.

“If it was a first mistake, truly a mistake that happened once, it would be easier to deal with … but this (problems with quality assurance) started back in 2014,” she said in an interview.

In addition, she noted that Willson did not report the error, leading Rumley to bring the circumstances of the death to the college’s attention.

Rumley said it was devastating to watch Bond go from a healthy, vibrant woman to suffering with a collapsed immune system and a body racked with infections.

“Her blood couldn’t clot. Her blood was like red water. She couldn’t talk. She couldn’t cough,” she said.

Willson did not return calls requesting comment.

Beverley Zwicker, the registrar of the regulatory body, notes the family has the right to appeal the sanctions to the Nova Scotia Court of Appeal.

She said the college bases its sanctions on legislative guidelines that balance the interests of patients with the pharmacists’ right to sanctions that are related to the severity of the mistake.

“These are difficult circumstances. We involve the family and talk to them about what they are looking for,” she said.

“In the end, the college determines the sanctions on what would be appropriate proportionate to the severity of the misconduct … with the goal of deterring repeat misconduct by the pharmacist.”

Zwicker also noted that pharmacists are often traumatized themselves by their errors. “They enter the profession to help people, not to hurt them. Their most significant sanction is that they live with this for the rest of their lives.”

In the other case, pharmacist Leanne Forbes had her licence suspended for 30 days after she failed to tell a patient of the risks of changing their drug therapy, which was done because one of the prescribed drugs wasn’t covered.

The patient was supposed to receive methadone and naltrexone, but Forbes told them the latter wasn’t covered under their drug plan and did not dispense it.

A toxicologist later determined that the patient’s Dec. 3, 2015, death was related to the withdrawal of naltrexone.

Zwicker said the two deaths are unusual, and the first she could recall during her time at the regulatory body.

“To have two in one year is unfortunate … tragic,” she said.

Michael Tutton, The Canadian Press