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Mock court case puts two senior pharmacists on trial

Attendees of the 2009 joint conference (of the Guild of HealthcarePharmacists and the United Kingdom Clinical Pharmacy Association) wereinvited to act as jurors in a mock court case involving the death of animaginary patient

By Gareth Malson, MRPharmS

Attendees of the 2009 joint conference (of the Guild of Healthcare Pharmacists and the United Kingdom Clinical Pharmacy Association) were invited to act as jurors in a mock court case involving the death of an imaginary patient. The scenario was as follows:

Mrs A, a designer and mother of three children, is admitted to anintensive care unit (ICU) with a rare but serious infection. She hasmultiple allergies, including one to penicillin, all of which aredocumented. Due to these allergies, the only suitable treatment optionis Blundermycin, an unlicensed antibiotic obtained from a Frenchmanufacturer in single-dose (50mg) vials.

After four daily doses of 50mg, the patient has been stabilised butonly two more doses of the drug remain in the hospital. Consequently,the consultant pharmacist for the ward requests a further supply. Thefollowing day (day 5), the manufacturer reports a six-week delay insupply, so another supplier is sought. On day 6, a Polish manufactureris found that can supply multidose vials of the drug (500mg) thefollowing day.

On day 7, the dose of antibiotic cannot be given as scheduledbecause the new supply has not arrived. Consequently, the consultantpharmacist goes to pharmacy stores to determine the whereabouts of thedrug, and it arrives while he is there. Since the dose is now severalhours late, the pharmacist asks the stores staff to book the drug outto the ICU and delivers it to the ward.

At 6pm that day, the drug is given to the patient. Shortly after,she goes into respiratory arrest and is pronounced dead at 6.30pm.

An inquest confirms that 500mg of the antibiotic was administered tothe patient. The administering nurse admits her error but points outthat the packaging had no English translation.

The coroners’ report confirms that the cause of death was a reaction toone of the Polish formulation’s excipients. He also declares thatstandard operating procedures within the pharmacy were not followed —namely that requiring a risk assessment to be performed on allunlicensed medicines.

Poor systems and supervision within the pharmacyare also highlighted by the report, and both the chief pharmacist andconsultant pharmacist are declared to have neglected their duty ofcare.


After the court case was acted out, the audience was split into three groups of 12 jurors. Each group deliberated on whether:

  • The chief pharmacist was guilty of corporate manslaughter (criminal charge)
  • The consultant pharmacist was guilty of gross negligence (criminal charge)
  • Either pharmacist should be reprimanded or struck off by the pharmacy regulator


None of the groups found the chief pharmacist guilty of corporate manslaughter, but two recommended a reprimand by the regulator. Two groups found the consultant pharmacist guilty of gross negligence and recommended he be struck off.

Readers are invited to post their comments on this scenario.

Hitting the headlines

Several pharmacists not assigned to a group of jurors were asked to think up some newspaper headlines that might be used to report the case. The fruits of their labour include:

  • “Expert” pharmacist kills mother of three
  • Polish wonder drug blunder
  • Foreign drug overdose kills designer mum
  • Patient polish-ed off
  • Designer dies from drug overdose disaster

Citation: Clinical Pharmacist URI: 10965953

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