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Was taking before he died. They were delivered by his local Boots Pharmacy in this pack a dosette box designed to make it easier for him to take medicine at the right time. On the outside is douglas lamonds name. But on the inside, the prescriptions are for a mr lampard. Douglas took more than 30 of mr lampards tablets, including medication to reduce blood sugar levels, which he didnt need. To witness him going into Heart Failure and then to subsequent cardiac arrest its the most devastating and horrible thing to see. This is the pharmacy in felixstowe where the mistake was made. An error so serious, Suffolk Police considered a charge of corporate manslaughter. Staff hadnt followed com pa ny safety procedures. I felt angry. I felt i wanted to throw a brick through every single boots store that i saw. I blame boots for. For my fathers death. In 2011, one manager had been concerned about pressure in boots pharmacies. Greg lawton reported to the superintendent pharmacist at boots headquarters. As a clinical governance pharmacist, he thought the company wasnt giving pharmacies enough money for staff. This is the first time hes spoken publicly. When i came into the Patient Safety role in 2011, i wrote a paper for the superintendents office, which set out those concerns, explained the issues with the staffing model and how that could put Patient Safety at risk. In 2012, in the same month as douglass death, police investigated another serious dispensing error. The boots uk board ordered an urgent investigation into more than 100 stores with the highest level of incidents. Greg lawton was looking at the north region. We spoke to pharmacists, to store managers and to area managers, and what those people were saying, absolutely, Staffing Levels was flagged as an issue poor Staffing Levels. There were issues with training that were identified, there were issues with the premises that were identified. The company told us that, after the investigation, it implemented a detailed action plan. It then commissioned Academic Research which, it says, found that pharmacies with higher levels of dispensing staff were associated with higher error rates. Deaths following dispensing errors are extremely rare. But six months after douglas, Arlene Devereaux died following a massive morphine overdose. It was her 71st birthday. She had osteoporosis. Even her hands were painful, you know, so thats why she was on zomorph. This time, a Boots Pharmacy at chesterfield, in derbyshire, dispensed six times the strength of morphine tablets prescribed by arlenes gp. The coroner concluded that arlenes death was accidental and there were clear opportunities for the error to be corrected. The pharmacist in charge said he must have been interrupted. We dont know why. It was shocking, and it kind of reminded you of the importance of the job that you were doing and strengthened your resolve to try and make a difference. Boots told us it dispensed more than 220 million prescription items in a year. There were just over 900 reported incidents where patients were harmed in some way. That ranged from needing minor treatment to permanent damage. So, statistically, that kind of incident is very, very rare. And some might not have been the pharmacys fault. Boots says, compared to other pharmacy chains, it has one of the lowest levels of harm and an industry leading approach to Patient Safety. The Pharmacists Defence Association union is the Largest Union representing the profession, with 25,000 members. Mark pitt worked as a boots pharmacist for 20 years. The pdau supports a third of boots 6,500 pharmacists and is involved in a legal battle to be recognised as a union there. Pharmacists have told us, working for boots, that theyre finding that, increasingly, there are less staff available, and that makes theirjob a lot more difficult and more pressurised. They are concerned about speaking up about problems in the workplace because they fear the consequences of what will happen to them. Boots uk pharmacy director is a qualified pharmacist whos worked for the company for 20 years. He spends a day a week out in its stores. Thatsjust not something i recognise. I personally have been able to raise whatever ive needed, whenever. I know we have an open and honest culture. If they fear speaking up, they can ring me direct, i absolutely assure confidentiality on that, just like we do for our whistle blowing hotline. They have a responsibility themselves as a pharmacist and a professional to speak up. The union says that many pharmacists it represents at boots are too frightened to speak out. Theyre scared theyll lose theirjobs. But two were prepared to be interviewed, as long as we protected their identity. Actors are speaking their words. Some days, you would easily describe the team as being at breaking point. Thats because simply the amount of work that has to be done, cant physically get done safely, and it cant physically get done without either working longer hours or working after the stores closed. Mistakes may not be picked up on, and that could ultimately lead to somebody possibly dying. Somebody missing medication, harm coming to people, small mix ups, really, just one tablet for another tablet. In september 2013, boots told its pharmacists about two very serious dispensing errors in six days. They were warned not to cut corners with company procedures. Two months later, there was another death. To find out what happened, im heading to the small Highland Town of kingussie. Margaret forrest trusted her local boots to supply the daily medicine she needed. Instead, mrs forrest, an active and independent 86 year old, was given a mrs frosts diabetes tablets. She had total belief in the system. She would have taken medicine given to her in total confidence that that was the right medicine that she had to take to protect herself and it didnt. At the end of the day, we all know human error. We all make mistakes, we all do, but unfortunately some mistakes are very tragic ones, and this was the case with my mother. Just like the cases of douglas and arlene, Company Safety procedures hadnt been followed in kingussie. Understaffing wasnt found to have contributed to any of the deaths. 0ne mistake like this is one mistake too many, and my absolute assurance is, despite having our industry leading record, we will continue. Continue to focus on minimising the chances of it happening again. Boots told us there have been no further deaths linked to dispensing errors at its pharmacies since mrs forrest died. Greg lawton wasnt investigating the deaths, but hed been looking in detail at staffing and budgets and was concerned that pressure from understaffing in boots pharmacies could lead to serious mistakes. He told a senior Patient Safety boss at Company Headquarters just how worried he was. I told her that i was terrified that something bad might happen to a patient, and the patient might be seriously harmed or a patient might die because of the inadequate Staffing Levels and the pressure that was placed on pharmacists and pharmacy teams. Greg lawton thought the way the company calculated how many staff it needed was fundamentally flawed. A few weeks later, he told management he was considering going to the pharmacy regulator. The information that i had and the things that i knew about the. Staffing levels, i think that that was the biggest risk to Patient Safety that id come across within the company. His concerns were immediately escalated to the highest level with the boots board, and he was invited to take part in ongoing work on staffing. So, whats supposed to keep patients safe . Well, as far as enforcing safe staffing goes, the only legal requirement is that, when a pharmacy is open, the pharmacist in charge, the responsible pharmacist, has to be there. All Pharmacy Companies must set their own safety rules, called Standard Operating Procedures. Theyre there to protect patients safety, and staff should follow them. But boots pharmacists weve talked to say time pressures mean they sometimes take shortcuts. You dont have the correct amount of time. You dont even have the correct amount of staff to do things on time. The staffing thing is huge. At best, youll barely have enough staff to just cope. We have Standard Operating Procedures in place for all of our operational procedures and our dispensing process in boots. Theyre recognised as being really high quality, industry leading. A lot of work has gone in to finding the processes that minimise the risk to our patients. Nobody should ever be in a position, and nobody should ever take the choice, to take any kind of shortcut. Comments on boots own pharmacy unscripted staff website in 2017, also show how concerned some pharmacy staff are. Pharmacists at boots do an excellent job, but often in very, very difficult circumstances. And considering its the largest Pharmacy Company in america and europe. It shouldnt be like that. Boots told us its own survey suggests four in five pharmacists were either comfortable or neutral about their workload, which is better than the rest of the nhs. The pharmacy regulator, the general pharmaceutical council, told us its inspected more than 2,000 boots pharmacies since november 2013. 26 didnt have enough qualified and Skilled Staff to provide a safe service. It says theyre now up to standard. That means only 1. 2 of boots pharmacies failed on the staffing standard, which compares favourably with all other pharmacies. Im absolutely confident that the resource is there to deliver the patient care. I am confident that we have enough staff. Community pharmacy is part of the nhs, and its funding is being cut. More prescriptions are being dispensed than ever before more than 1 billion a year. And as the population gets older, theyre becoming more complex. I think my record is 37 medicines that theyre on, and you have to check each one for suitability. Youre trying to do that in a busy, hectic environment, and youve got all the other tasks to do. Accuracy is crucial. Boots says pharmacists should only check their own work as a last resort. But the pharmacists we spoke to told us, in their experience, when theyre busy, that doesnt always happen. Often, you end up having to self check medication. Often, youre in a situation where youve got no staff at all and youre having to dispense medication and then self check that medication. Every day, therell be an occasion where ive got to self check on all of the shifts that i work. All our prescriptions are checked twice before they go out. Less than 1 of the time, and 1 of the prescriptions that we dispense, a pharmacist will return to their own work and check that prescription themselves. If we have pharmacists who think theyre in situations where they are having to do that when they shouldnt, they must, they have a professional responsibility to raise that. If the pharmacist in charge thinks their pharmacy is unsafe, one option they have is to temporarily close. In a union survey of more than 400 boots pharmacists, 31 said theyd closed pharmacies because theyd been concerned about Patient Safety. More worryingly, 160 out of 212, whod considered it, said they didnt close because they didnt believe their decision would be supported. You end up staying open in these unsafe situations and, out of your own goodwill, try to catch up on, maybe, backlogs or try to reorganise things. 160 is a very small sample, but its an important sample. If we have got people who genuinely feel like that, then it does concern me, so please, please, please do come and speak to me and give me the chance to sort it out. This is a very, very extreme circumstance. We will always support a local shop, whether thats with resource, whether thats with time, to be able to stay open. So how do pharmacies decide how many staff they need to keep patients safe . Theres no regulation to say, if you dispense this many prescriptions, you have to have this many staff. To calculate the workload, boots uses a complex model, which includes the time it takes to dispense various prescriptions. Injuly 2014, greg lawton was asked to be part of a team which recalculated those times. The work that we did on time standards was regarded as very robust work. It was done alongside external co nsulta nts, and they called it world leading. The team reported back that boots needed to spend tens of millions more on its pharmacies. We calculated the amount of investment from the time standards and from other operational considerations and to meet the expectations that the company had of pharmacy staff and its stores, and that was in excess of £100 million additional investment every year that was required to fund that. Boots says that only greg lawton held the view that in excess of £100 million a year was required. The company told us it did make significant additional investment in pharmacies following the time standards review, but says the specific figure is commercially sensitive. Greg his opinions and his concerns left the business over two years ago and arent relevant to boots today. We continue to invest in more people, more pharmacists, than ever before. Thats into our shops and its into our processes, helping to make things more safe. As the uks biggest pharmacy chain, boots is providing a crucial nhs service. We asked the company to explain exactly how it works out how many staff to put in almost 2,400 pharmacies. It refused. The company told us the time standards, which are part of the calculation, are a trade secret which could be copied by its competitors. Lloyds, the uks second largest pharmacy chain, has provided both its time standards and how theyre used to work out Staffing Levels. Boots says you cant compare one company with another, and it shares the principles of how it works out staffing budgets with line managers. Ethics expert whos trained the last two boots superintendents the pharmacists in charge of Patient Safety. I dont really accept that they are trade secrets. If theyre confident that their staffing calculations do maintain Patient Safety, i dont see why they should be unhappy to share them. In may 2016, in scotland, Steven Forrest represented his family at the fatal accident inquiry into his mothers death. He wanted to know what happened before the prescription was handed over. The pharmacist in charge exercised her right not to appear. Instead, her witness statement was read out. The mere fact that that is not. We didnt have the opportunity to talk to the pharmacist about that, to find out what her views were on that, was very, very alarming to us. That was a key, key witness. But steven did cross examine other members of staff. The fatal accident inquiry heard that shortcuts were taken if they were too busy or tired. In the court, as the evidence presented by the pharmacy staff themselves that were operating, that were understaffed. At least two of the staff werent. There one was on honeymoon and one was off sick. The sheriff concluded the pharmacy was quiet at the time and understaffing didnt play a part. A member of staff hadnt followed company procedures. The name and address hadnt been checked when the tablets were handed over. There was no defect in the actual system of working. Margaret forrests death was caused by human error. Its all very well saying, we have Standard Operating Procedures, but, if theyre not being followed and youre not addressing why theyre not being followed, these incidents will continue to happen. Staff at kingussie were given refresher training. In a personal injury claim by the family, boots uk admitted vicarious liability for the negligence of one of its staff. Last march, the inquest into douglas lamonds death was held in suffolk. Staff told the coroner on the day the prescription went out, theyd been very busy and under pressure. They said theyd kept telling their area manager they didnt have enough space to do theirjob. The Police Report said that meant they werent following the companys Standard Operating Procedures. The coroner said they were operating in a difficult situation. Boots told us it found no record of staff raising concerns with the manager. The pharmacist in felixstowe was eventually given a police caution for an offence under the medicines act. When detectives in suffolk investigated douglass death, they wanted to see boots own internal investigation report. The company was entitled to refuse under legal professional privilege. While the detective in charge acknowledges that, he feels the company had a moral responsibility. Do i feel that boots gave us the full cooperation . No, i dont. I do think, particularly a Big Corporate Company such as boots, who have a significant responsibility towards public safety, have a moral duty to cooperate fully with any police investigation. And also they have an overriding duty to demonstrate transparency to the family. Boots says it cooperated fully with the police, and legal privilege allows staff to make full and frank reports. The company says it wishes to apologise again to the families of the three patients who died following dispensing errors. We wanted to find out how many errors there are in community pharmacy, but it hasnt been easy. We do know that, in a year, more than 17,000 incidents involving medication were reported to the nhs across the industry. But that reportings voluntary, so the realfigure could be higher. A new law has gone before parliament. Its hoped itll encourage pharmacists to report more errors, so that lessons can be learned. In september 2014, at boots uk headquarters, greg lawton was on the verge of going to the regulator. He wanted Senior Management to go with him. He had a crucial meeting with the then superintendent pharmacist, who was the head of Patient Safety and the director of stores for boots uk at the time. That was the most difficult point in my career, i would say. Very difficult. Its like a weight that you would carry with you all of the time that would never leave you, even outside of work. And, um. Sorry, if we could just pause for a minute, id appreciate that. The superintendent told me that. He felt that nobody. Out there would welcome the conversation. Knowing that all that i had done was to try to protect patients, that was very difficult. Boots says the superintendent pharmacist never attempted to dissuade mr lawton or any member of staff from whistleblowing, and he was supported throughout. It took another six months, but greg lawton did become a whistleblower. He met the gphc to discuss his concerns. I felt a sense of relief because i felt that finally somebody would be able to do something about it. The gphc was aware the troops would be coming and the company would be investigated. Shortly afterwards, greg lawton resigned. He eventually presented the regulator with a 55 page witness statement and dozens of supporting documents. He shared his detailed evidence with the Pharmacists Defence Association union, who hes been working for. Since september 2015, boots says its increased the number of pharmacists by 430. Pharmacy technicians have gone up by more than 360. Staff with pharmacy capability has risen by more than 2,400. Those last two groups include staff in training. The Company Agrees theres been an increase in pharmacists workload, but says its been fully funded. In december 2016, the department of health began cutting nhs funding for community pharmacy. By march, budgets will have fallen by more than £200 million. The owners of lloydspharmacy announced, as a result, theyre closing almost 200 stores. Also in december 2016, the general pharmaceutical council responded to greg lawtons evidence. It recognised the very difficult position he was in and said his information was invaluable. But for greg lawton, the response was a huge disappointment. They told me that they were going to review their inspection model as a result. They didnt interview a single person, and they concluded that there wasnt any problem at all. The gphc told us it conducted a thorough investigation looking into both mr lawtons concerns and evidence from boots Senior Management. It concluded there wasnt sufficient evidence to suggest a risk to Patient Safety across the organisation, and understaffing was not systemic. However, it told us the information provided by mr lawton assists them when inspecting boots pharmacies. The regulation around pharmacy is inadequate. We need regulatory standards to specify what the Staffing Levels must be in pharmacies. I agree with that. The idea that Staffing Levels are too difficult to set and dont allow sufficient flexibility its about time that was challenged. Id like to see the powers they have against corporate employers re examined, and i dont think that anybody could have envisaged that the employment of pharmacists would devolve on such enormous, Large International companies. The regulator told us pharmacy owners are best placed to set Staffing Levels. Its also providing new Patient Safety guidance this year, which will stress that owners must provide enough qualified staff. Our pharmacies are busy places, but they are safe places. We have an industry leading Patient Safety record, we continue to invest, we continue to improve both our processes, our systems, our operations, to get even safer into the future. We do not want this to happen again, to someone elses mother, grandmother or sister. As long as the public, the patients, who are ultimately the ones at risk, and ultimately the ones that were meant to be serving, as long as they dont know, then nothing will ever change. Id like to think that this could be a catalyst to force an industry change. The weather through the west of the British Isles has been dominated by this with the front. Overnight, the rain will tend out in them number of locations, perhaps the high ground in the north holding onto it for a length of time. If the crown breaks, you may end up with a touch of frost. That rain, what is left of it, may dissipate throughout the day. Generally cloudy day. A lot of cloud around. Temperatures a fraction back on where we have had them of late. Late in the day, a speu them of late. Late in the day, a spell of wet and windy weather initially into the North Western quarter of scotland and through the night and through monday, that pushes across the tuition isles and following on behind, things turn much colder, a lot of showers around, some of those will be wintry. This is bbc news, im vicki young. The headlines at 9pm officials from across government are holding talks this weekend to discuss the future of the troubled construction firm, carillion. The governor of hawaii apologises after officials mistakenly issued an alert warning residents of an imminent Ballistic Missile attack. Warnings of a tooth decay crisis amongst children in england. A record 43,000 operations to remove rotting teeth were carried out last year. Also four britons break a world record for rowing across the atlantic. The amateur crew, dubbed the four oarsmen, travelled from the Canary Islands to antigua in 29 days beating the previous record by six days. The task of getting us onto the challenge is the Worlds Toughest row. We were out there just preparing as best we can for it and giving it our all

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