A West Midlands pharmacist has been reprimanded by the Statutory Committee after he had dispensed adrenaline ampoules to an addict instead of methadone. The patient, who had suffered side effects after he injected one of the ampoules intravenously, had not been advised to seek medical attention.

When it met on 9 December 2003, the committee inquired into the case of John David Bryant, of 9 White House Green, Solihull, West Midlands. A complaint had been received from the Council of the Royal Pharmaceutical Society alleging that on 11 October 2002, while locum pharmacist in charge of Brights Chemist, 1 Middlemore Road, Northfield, Birmingham, Mr Bryant had dispensed in error three ampoules of 0.5ml adrenaline injection BP 1 in 1000, labelled as methadone, on a prescription calling for three methadone BP ampoules 50mg/ml It was also alleged that Mr Bryant had failed to advise the patient concerned to seek immediate medical advice after he had injected one of the ampoules; that he had failed to advise the patient’s father that his son should seek immediate medical advice; and had failed to contact the patient’s doctor or drug addiction clinic, or the superintendent pharmacist of Brights Chemist.

Geoff Hudson, of Penningtons (solicitors) appeared at the meeting to present to give the facts of the case.

Mr Bryant, who was present at the inquiry, represented himself.

The committee heard that the patient to whom the adrenaline ampoules had been erroneously dispensed was an addict; he had administered one ampoule to himself intravenously shortly after it had been dispensed. Almost immediately, he had felt great pressure in his head, his heart began to race and he had been unable to control his hands. He had returned to pharmacy in a state of distress, told Mr Bryant what had happened and returned the unused ampoules of adrenaline.

Mr Bryant had assured the patient that he would be “all right” so long as he took no other medication for four hours. He did not, however, advise him to seek medical advice. Nor did he contact the addiction clinic that had issued the prescription, the patient’s doctor, the pharmacy manager or superintendent pharmacist. When the patient’s father had visited the pharmacy later the same day, he had not suggested that medical attention should be sought.

The patient himself saw his doctor on 14 October, when his blood pressure and heart rate were found to be very high. He was advised to attend the local hospital accident and emergency unit.

A trainee dispensing technician at the pharmacy had been sufficiently concerned that Mr Bryant had not informed the branch manager that she sent a text message alerting her to the incident and made an entry in the error book.

Giving the committee’s decision, the chairman (Lord Fraser of Carmyllie, QC) said that Mr Bryant, who had been a pharmacist for “44 distinguished years” had not tried to excuse his error.

The original error had been that the adrenaline ampoules had been put in the Controlled Drugs cabinet and then put in a bag for the patient. Nevertheless, said the chairman, Mr Bryant had not checked what was in the ampoules, only that there were three of them and they were not damaged.

When the patient returned to the pharmacy after having injected one of the ampoules, Mr Bryant had appreciated immediately what had happened. He had then decided, erroneously, after observing the patient and concluding that his symptoms were subsiding, that he should simply advise him to lie down and take none of his other medication.

Mr Bryant had consulted the British National Formulary, where it stated in relation to adrenaline/epinephrine “IMPORTANT. Intravenous route should be used with extreme care”. It was odd, continued Lord Fraser, that having looked that up he had not then advised the patient to seek medical advice.

The dispensing error had been compounded by Mr Bryant’s failure to advise and inform, said the chairman. That amounted to misconduct such as to render him unfit to be on the register. However, Mr Bryant had been open and frank with the committee and had now retired from practice.

The committee reprimanded Mr Bryant.