A pharmacist is facing disciplinary proceedings after admitting she did not advise the carers of a customer, who later died, about the dangers of combining two prescribed medications.
Alice Parnell (77), of Old Knockmay Road, Portlaoise, died of heart failure in Portlaoise hospital weeks after taking the antibiotic Klacid, or clarithromycin, along with her prescribed blood-thinner, Warfarin.
A Pharmaceutical Society of Ireland fitness-to-practice hearing involving pharmacist Audrey Kingston was told that Warfarin is an “alarm bell” medication and the threat of a serious interaction between it and Klacid would be well-known among pharmacists.
Mrs Parnell’s daughter, Lisa Parnell Dunne, told hearing she was not advised by Ms Kingston when handing in the prescription about the risks of combining the medicines. The inquiry heard that Ms Dunne’s father, Kieran Parnell, was not told either when he later collected the medication.
Ms Kingston, who was named ‘pharmacist of the year’ two days after Mrs Parnell’s death on May 16th, 2019, was the supervising pharmacist at Chemco Pharmacy at SuperValu shopping centre in Portlaoise, where the prescription was collected.
Ms Dunne, herself a pharmacy technician, told the hearing she presumed Ms Kingston had spoken with her mother’s GP, Dr Gerald White, and that it was decided to leave her on the medications.
Sent to A&E
When Mrs Parnell went to her regular Warfarin clinic the following week, she was told to immediately attend an accident and emergency unit because of the results of her blood tests. She was later admitted to Portlaoise Hospital where medics tried to stabilise her condition.
The following morning, Ms Dunne said, consultant endocrinologist Dr Jay Sharma told her the Klacid had interacted with the Warfarin and “that was why (her mother’s bloods) were so high”.
She told the hearing that she confronted Ms Kingston the following day, explaining that her mother had been hospitalised because of a suspected interaction in her medications. Ms Dunne said Ms Kingston told her she had not contacted the customer’s GP because she “assumed she needed” the Klacid.
Asked if she had spoken to Mr Parnell when he collected the medication, to advise regular tests would be needed to check for interactions, Ms Kingston said: “I would have spoken to your dad, yes,” the inquiry was told.
In a written statement, Mr Parnell said he was not advised of any risks and was simply handed the medication by an assistant.
Ms Dunne alleged the pharmacist then “changed subject” and that she felt Ms Kingston “was trying to avoid talking about the prescription and the whole situation”. The supervising pharmacist said she “would put it on file (for Mrs Parnell) not to have that medication again”.
‘Completely their fault’
Despite repeated attempts to get through to Chemco headquarters in Kilkenny, Ms Dunne said it took several days before Chris O’Grady, a director of the pharmacy chain, got back to her.
She said Mr O’Grady said he was “very sorry, it was completely their fault”. In the meantime, medics had advised her that Mrs Parnell was going to die.
Ms Kingston later phoned Ms Dunne and “said she had told lies to me” and that “she got confused with the previous prescription Mam had had,” she said.
The pharmacist was “very polite and apologetic” but “admitted” she had not spoken with her father when he collected the medication, the hearing was told.
Mr Parnell, in his written statement, said he was married to Mrs Parnell for nearly 51 years and they “did everything together”.
The inquiry heard Mrs Parnell was on a number of medications, including for blood pressure after a bypass and having a defibrillator fitted three years earlier, and had been “doing very well”. Mrs Parnell had a number of conditions, including issues with her liver and kidneys.
Mr Parnell said his wife was in hospital for a month, including in intensive care and the coronary care unit, before her death which he called “a day I will never forget”.
Dr White later called to him to offer his sympathies and said “what happened had nothing to do with him,” according to Mr Parnell’s statement. It was a “pity Dr White didn’t send Alice into hospital a month before, she would probably be still around,” he added.
Spikes
Ms Dunne agreed with Ms Kingston’s solicitor that her mother’s blood tests had returned to normal within 36 hours of being admitted to hospital. Her mother had suffered spikes before but it was “unusual”.
She told the inquiry Mrs Parnell’s organs came under pressure as medics stopped some of her medications to try and “balance everything” because “everything was starting to shut down, it was a constant battle, from the damage that was done”.
“At one stage they were stopping the Warfarin, then starting it again because of the fear of a clot.. Dr Sharma did everything he could to try and get back, but he did say it was trial and error,” she added.
She said Dr Sharma told her the mix of Warfarin and Klacid ‘caused the problem’ and that lots of things killed her mother, “but he indicated this was nearly like petrol on a burning fire”.
It is alleged that Ms Kingston supplied Klacid to Mrs Parnell, without advising her husband or daughter about the potential interaction with her existing Warfarin medication and the need for increased tests on her rate of blood clotting. It is further alleged she failed to consult with Mrs Parnell’s GP about combining both medicines.
Keith O’Hourihan, a Cork-based superintendent pharmacist called as an “expert witness”, said pharmacists should consult customers, or their carers, when administering drugs with a “sizeable interaction profile” like Klacid and Warfarin. There also ought to have been an “alert” on the pharmacy system about potential interactions between the drugs, he said.
Warfarin is “an alarm bell medicine”, he said, adding that he would be “automatically quite concerned to be sure it was safe” when prescribing.
“As antibiotics go clarithromyn has a large interaction profile,” he said, adding that a failure to advise would amount to poor professional performance.
Mr O’Hourihan said records show that Ms Kingston acknowledged the serious potential for interaction and that she could have phoned Mrs Parnell’s doctor but did not.
The inquiry continues.