Annette Charlton · Prevention of Future Deaths report

On 7th October 2014 I commenced an investigation into the death of Annette Charlton aged 75. The investigation concluded at the end of the inquest on 6th January 2015. The conclusion of the inquest was natural causes.

The deceased suffered from emphysema and lung Fibrosis requiring continuous oxygen therapy. On 24/09/14 her GP prescribed a course of antibiotics – Phenoxymethylpenicillin 250mg. Her husband attended their local pharmacy. She was inadvertently dispensed Naproxen 250mg. On 27/09/14 she was admitted to Queen Elizabeth Hospital Birmingham very short of breath. They realised the error in the medication and prescribed antibiotics. She died on 28/09/14.

The cause of death following post mortem examination was confirmed as end stage pulmonary fibrosis and bronchiectasis. Neither the pathologist, nor a Professor from Queen Elizabeth Hospital Birmingham were able to say that the delay in antibiotics had caused or contributed to the death. Both were able to confirm that the naproxen had not caused the death.

The dispensing error occurred as the 2 tablets were in almost identical looking boxes and made by the same manufacturer. The Naproxen had been put on the Phenoxymethylpenicillin shelf by mistake. A further mistake had occurred when the pharmacists failed to spot the wrong medication had been chosen.

I attach a colour copy of the medication boxes to show the similarity.

I heard evidence at the inquest that this was a national problem namely drug companies packaging medication in almost identical boxes which meant dispensing errors had become "very common issues"

Please note the pharmacist in question has already taken remedial action and introduced new processes and procedures within his pharmacy to avoid similar events.

(1) Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.