Derrick Twaite · Prevention of Future Deaths report

On 26th November 2015 I commenced an investigation into the death of Derrick TWAITE, age 86. The investigation has not concluded, but evidence has been disclosed that indicates a situation exists that should be brought to the attention of relevant practitioners.

1) Mr Twaite had his medicines dispensed in a multi compartment compliance aid. One of his medicines was Finasteride, which is presented in a multi tablet bubble pack. Finasteride tablets, in their bubble where snipped from the multi-dose pack and placed in the compartments of the compliance aid. Mr Twaite appears to have swallowed one Finasteride tablet, still in its sharp edged bubble pack segment. This caused a gut perforation which led to his death.

1. That although this practice of snipping tablets from the unit dose packs, still in their bubble, and place them in the compartments of multi-dose compliance aids is contrary to the advice of the relevant professional bodies, it apparently still being done by dispensing pharmacists and dispensing general practices..