A CANCER patient who was mistakenly dispensed an incorrect drug from a Dublin pharmacy died almost two months later after the medication caused a drastic deterioration in her health, an inquest has heard.
Rita O'Connor (59), Rowlagh Crescent, Clondalkin, Dublin, died at St James's Hospital on March 2nd, 2007, just two months after she was incorrectly dispensed capecitabine (Xeloda), a drug for treating colorectal cancer, instead of another drug, mycophenolate mofetil (Cellcept.)
The human error was made at the commercial pharmacy on the main concourse of St James's Hospital on January 3rd, 2007, Dublin City Coroner's Court heard and the pharmacist who dispensed the medication no longer works there.
Ms O'Connor, who was diagnosed with low grade lymphoma in 1991 and who had undergone a wide range of treatment for the condition including a bone marrow transplant, had been discharged from hospital that day.
While her liver function tests were moderately abnormal, consultant histopathologist at St James's Hospital Dr Elizabeth Vandenberghe told the court she "would have been confident of controlling it".
However, a review in the day unit on January 5th and 8th indicated a deterioration in liver function and, by January 12th, Ms O'Connor had grossly abnormal liver function tests, which caused Dr Vandenberghe great concern.
A subsequent inquiry revealed that Ms O'Connor had been dispensed capecitabine (Xeloda) - which was toxic to her liver and contra-indicated in her condition - rather than of mycophenolate mofetil (Cellcept).
The prescription was correctly written, but incorrectly dispensed, the court heard, and Ms O'Connor was re-admitted on January 12th, to monitor the side-effects of capecitabine. Her condition deteriorated and she died on March 2nd.
Dr Vandenberghe said the adverse effects of not receiving the medication she was prescribed, as well as receiving an incorrect drug which was toxic to her liver, would have explained Ms O'Connor's massive liver dysfunction.
As a result of the damage to her liver, doctors were also unable to give her the first line of treatment for graft versus host disease, and had to resort to suboptimal treatment with steroids rather than mycophenolate.
Pharmacy proprietor Damien Conaty told the court the pharmacist in question "completely misinterpreted" and that it was "horrendous and indefensible".
"She should have known the difference, there's no doubt about that. The lady was in her 30s and she had plenty of experience. She was a registered pharmacist," he said.
The court heard that another staff member had offered to stay and assist the pharmacist in dispensing Ms O'Connor's prescription, but the pharmacist had sent her on her break, eliminating the double-check which is usually carried out.
Coroner Dr Brian Farrell said he was satisfied that there had been a mistake in the dispensing of the prescription, which accelerated the liver dysfunction and was a material factor in the cause of Ms O'Connor's death.
"I accept the dispensing error was a human error. I think it was a personal error of the pharmacist."
He recorded a verdict of death by misadventure.
Dr Farrell expressed his condolences to all of Ms O'Connor's family including her husband, Edward, her two children, Natalie and Gavin, and her sister, Elizabeth, who were in court.
Speaking outside the court, Mr O'Connor said he was very bitter about what had happened to his wife, whom he knew since he was 16. "I was robbed of my wife well before her time. We were planning to sell the house and to move to Spain."