The chemist’s deputy superintendent pharmacist Dr Josie Moss said “sorry” on the third day of a fatal accident inquiry at Inverness Sheriff Court into the death of Margaret Forrest, from Kingussie.
She had been given tablets which should have been handed out to another woman suffering from diabetes. Mrs Forrest died on 14 November, 2013, after falling into a coma brought on by ingesting six gliclazide tablets over three days.
Dr Moss told Sheriff Margaret Neilson no changes had been made to Boots’ standard operating procedures (SOP) as a result of the tragedy.
She said: “They have been refreshed and re-emphasised to all our staff in our 2,400 branches across the UK. Packages for patients with similar names have a warning label and there is a requirement to sign a docket. But no changes have been made to our SOPs because it would increase the risk of more errors. This was caused by human error and not our procedures. If they had been followed it would not have happened. We have a threeway security check which is carried out millions of times a day across our branches. On this occasion it wasn’t.
“We are keen to learn from our mistakes and we know human beings come to work and there is a risk that something can go wrong, however good the processes, and there can be tragic consequences.
“Mrs Forrest should have got a pack of nine medicines. But she got a pack of only two. There was a failure to reconcile her name and address with what was on the prescription and what was on the bag.”
Mrs Forrest, who had been backpacking around the world into her eighties, was put on to a Medisure system of getting her pills only weeks before her death. Her GP was concerned she would take the wrong medicine at the wrong time and ordered the change.
Her tablets were placed by the Kingussie branch of Boots into a monitored dosage box which she collected weekly.
But Mrs Forrest picked up a box lying next to hers whichshould have been delivered to a Florence Frost, who has diabetes. It was the drug Mrs Frost should have been given which killed Mrs Forrest. She was found unconscious in her flat by son Billy, 65, and never regained consciousness.
Her son Steven, who represented the family, said: “It is tragic that what was meant to protect my mother killed her. I note Dr Moss’s apology in her report into my mother’s death, but today was the first time we have had an unreserved apology from Boots.”