CASE 1: Venlafaxine Overdose
Dispensing practice, policy is for dispensers not to open and add drugs to dosette
boxes once finalised. Patient taking several medications with dosette box and
supervision of adult daughter.
Patient under care of hospital psychiatrist seen in clinic and sent with plan for cross
tapering of mirtazapine to venlafaxine over 2 weeks. Letter for consultant detailed plan
as:
 Reduce mirtazapine to 30mg daily and start venlafaxine 37.5mg BD for 14 days
 Venlafaxine 75mg BD thereafter.
Prescription from hospital brought to dispensery and read:
 Venlafaxine 37.5mg BD 28 tablets
 Venlafaxine 75mg BD 28 tablets
 Duration of treatment 28 days
 (No mention of mirtazapine)
Medications dispensed as prescribed. Dispensing staff observed daughter opening
dosette box and adding both strengths of venlafaxine twice daily. Was approached
and following clarification with duty doctor patient given correct regime.
Actions taken
 Letter written by duty doctor to prescribing hospital doctor identifying issues and
asking for clearer instruction on prescription given to patient (e.g. venlafxine
37.5mg BD for 14 days THEN venlafaxine 75mg BD to continue)
CASE2: Rash decisions
Mr M, a 56-year-old developed severe pain in his left foot and made an appointment to
see his usual GP, Dr P. Dr P knew him well, having diagnosed Mr M with CKD several
years earlier. Dr P suspected he was suffering from gout on this occasion and
prescribed diclofenac, with omeprazole cover, since he was also taking aspirin.
Less than a month later, Mr M’s symptoms deteriorated and he requested a telephone
consultation with his doctor. Dr P arranged for him to have a further prescription issued
for diclofenac and omeprazole, and organised blood testing with the nurse to monitor
his renal function.
His blood tests had confirmed gout, alongside the ongoing CKD. He was commenced
on allopurinol, with the advice that he should double the dose of this after ten days of
treatment.
A fortnight after commencing the new medication (now on 200mg of allopurinol) Mr M
started to feel unwell. He reported nausea and an itchy skin on his torso and face. Dr
P concluded that the rash was likely to be secondary to a viral illness, and
antihistamines were prescribed. That night, the rash seemed to be getting worse, so
Mr M consulted with Dr P again the very next day, and a course of prednisolone was
commenced. The allopurinol was briefly discussed, and the patient was advised to
continue taking it at a dose of 200mg daily.
The situation continued to deteriorate and Mr M had two further appointments with Dr
P over the course of the next week. His steroids were initially increased, and when this
failed to improve symptoms, Dr P suggested the allopurinol should be discontinued. To
complicate matters further, Dr P forgot to document the second consultation since he
had a busy surgery. Three days later, Mr M developed generalised swelling, throat
discomfort and difficulty breathing. Dr P spoke to the patient over the telephone and
advised he was likely to be suffering from thrush.
Dr P realised at this stage he had failed to document his previous consultations so
made some brief notes, without indicating he was doing this retrospectively. The next
day Mr M was admitted to hospital by ambulance and diagnosed with StevensJohnson syndrome. He spent a week being treated in ICU with septicaemia and renal
failure, but unfortunately died as a result of these conditions.
Causation reports concluded that on the balance of probabilities, the patient developed
Stevens-Johnson syndrome due to allopurinol, and experts were critical of Dr P’s
decision to initiate the treatment after just one attack of gout, and at an increasing
dose.
Outcome:
Experts agreed in this case that Dr P had ample opportunity to make the connection
between the rash and the allopurinol, and furthermore, the steroid treatment, which is
likely to have contributed towards the ulceration, could have been avoided. The case
was indefensible and was settled for a moderate sum.
CASE 2: Repeat offender
Mrs B was a 49-year-old who, for 18 months, had been increasingly troubled by heavy
irregular menstrual bleeding. She was referred to a gynaecologist who carried out a pelvic US
and an endomentrial biopsyThe gynaecologist told Mrs B that he would be writing to her GP
with his opinion and treatment recommendations for HRT.
Mrs B was advised to go and see her GP to get a prescription for HRT in two weeks, allowing
time for the clinic letter to reach the GP. In the meantime, the gynaecologist scribbled down
the name of the recommended HRT and gave it to Mrs B.
Two weeks later, Mrs B took the afternoon off work and went to see Dr M, a locum, at her GP
surgery. Unfortunately no clinic letter was available to Dr M on the practice computer notes, Dr
M attempted to find out if a paper copy of the letter was available but she had no success.
She surprised Dr T by saying that the HRT wasn’t helping her bleeding that had recurred and
Dr M was running late and was sensitive to Mrs B’s frustration at having taken time off work for
“a waste of time”. Eager to help Mrs B, Dr M looked at the handwritten note the gynaecologist
had given her. The writing was barely legible, but Dr M thought the medication looked most
like unopposed oestrogen.
Mrs B’s blood pressure was satisfactory and it was recorded that Dr M counselled her about
risks of breast cancer and thromboembolic disease. Mrs B left with a prescription for
unopposed oestrogen.
Mrs B continued to be prescribed three-monthly prescriptions of the unopposed oestrogen.
The GP who signed the repeat, Dr P, saw from Dr M’s consultation notes that Mrs B had been
seen recently by a gynaecologist and the prescription had started as a result of this, and was
therefore satisfied it was appropriate.
At six months she was seen in surgery by Dr T for a review of her HRT. Dr T did the same
recording that a course of unopposed oestrogen was started by the gynaecologist
The prescriptions continued for a year, when Mrs B was again called for a HRT review. At this
point she surprised Dr T by saying that the HRT wasn’t helping her bleeding that had recurred
and which was, in fact, heavier and more persistent than ever.
Dr T realised that for many months Mrs B had been mistakenly prescribed an unopposed
oestrogen and now had heavy bleeding. Dr T apologised to Mrs B and also explained that she
needed to be quickly referred back to the gynaecologist for investigation. She was referred
urgently and in view of her history of increasingly heavy bleeding and prolonged exposure
to an unopposed oestrogen, a hysteroscopy was carried out. This led to a diagnosis of
endometrial cancer. Mrs B had a hysterectomy and made a full recovery.
She made a claim against all the doctors involved in her care at the GP practice. The
gynaecologist’s original letter was eventually found in the patient’s notes.
Outcome:
 The incorrect prescription could not be defended – Dr M was responsible for her
actions.
 An expert gynaecologist advised that the patient’s subsequent problems were probably
a result of this (although there was a low probability that they may have occurred in any
case). The practice was liable because there was no system in place to check the
prescriptions and uncover Dr M’s mistake.
 The confusion could have been avoided if the consultant had issued the first
prescription.
 The claim was settled for a moderate sum.