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Inquest Opens Into Death Of Richard Anthony Lee

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Before HM Assistant Coroner for South Yorkshire (East District) Ms S L Slater

Doncaster Coroner’s Court

Opening 25 June 2018 – Expected to last three days

Richard Anthony Lee died on 15 December 2016. His death occurred after a pharmaceutical error resulted in Mr Lee receiving double his medication. Mr Lee died following a significant overdose of one of his prescribed medications.

Between May 2012 and November 2013, three people died due to dispensing errors, at a Boots Pharmacy. The risk of pharmacy errors was further highlighted by a BBC Inside Out programme in January 2018. The 30-minute Inside Out investigation, ‘Boots: Pharmacists under pressure’, explored the alleged workplace pressure placed upon pharmacists working for the health and beauty giant and how this could potentially lead to dispensing errors. A representative for Boots indicated during this programme that there had been no further fatalities linked to dispensing errors since 2013.

Circumstances of Mr Lee’s death

Between 4 October and 8 November 2016 Mr Lee received his prescribed medication from Boots Chemist Church Street, Askern, Doncaster, in a Medisure pack. His delivery consisted of 4 weekly medisure packs that would last him one month.

In early November, the Pharmacist at Church Street Chemist refused to handle one of his medications and as a result the handling of his prescription was moved to another Boots Pharmacy on Frenchgate, Doncaster. On the 14 November due to concerns that this Pharmacy was too far away from Mr Lee, the handling of his prescription was transferred to a 3rd Boots Pharmacy which was attached to Mr Lee’s GP Surgery.  On this date the Pharmacist at Frenchgate was told that she should stop the dispensation of Mr Lee’s medication from then on. The Pharmacist did not make a record of this conversation in the communications book nor did she tell other staff members. She went on leave the next day.

On 6 December Mr Lee received a 4 x medisure packs from Frenchgate for the next month. The next day, the same medisure packs were delivered but from his new Pharmacy to cover the same period.

On 15 December, Mr Lee was found on the floor in his bedroom. An ambulance was called and he arrived at Doncaster Royal Infirmary at 2.06pm.  Mr Lee was pronounced deceased at 18.49hrs following a cardiac arrest caused by a significant overdose of one of his medications. It is believed that Mr Lee took his medication from both medisure packs that had been delivered each day between 7-15 December.

The family hope that this Inquest will explore the circumstances leading up to the dispensing errors that were made in the weeks leading up to Mr Lee’s death which caused him to receive 2 x medisure packs and therefore double the dose of his medication, which proved to be fatal.