Health Practitioners Disciplinary Tribunal, 1236/Phar21/514D, (6 May 2022)
The Director of Proceedings filed a charge of professional misconduct against pharmacist Feras Dawood (Mr Dawood) in the Health Practitioners Disciplinary Tribunal (the Tribunal). The charge included two Particulars concerning:
- Mr Dawood’s failure to correctly identify a dispensing error in his role as the checking pharmacist; and
- his subsequent attempts to cover up his mistake and attribute blame to another staff member, Ms A.
In March 2019, Ms B presented to her local pharmacy (the pharmacy) with a prescription for 13 medications, including rifaximin (an antibiotic). Mr Dawood was the managing director and majority pharmacist shareholder of the pharmacy.
On 3 May 2019, a pharmacy technician, Ms C, processed the future blister pack foils, dispensing labels, and certified repeat copy (CRC) forms for Ms B. A CRC is generated by a pharmacy’s computing system when a repeat medication is processed for dispensing. It is then printed and used for packing and checking the repeat prescription. CRCs are signed or initialled by the pharmacist or technician when the medicine is packed, and checked, prior to being given to the patient.
There was insufficient rifaximin, as well as another medication, clonazepam, to fill the prescription, and Ms C processed an order for these medications, which arrived at the pharmacy the next day.
On 9 May 2019, Ms C prepared Ms B’s repeat prescriptions. She incorrectly dispensed rivaroxaban instead of the prescribed rifaximin. Ms C signed the ‘packed by’ section of the CRC with her initials. Mr Dawood later checked the medication prepared for Ms B and failed to detect the dispensing error. He signed the ‘checked by’ section with his initials.
Ms B collected her medications on 16 May 2019. She became increasingly unwell and was hospitalised on 24 May 2019 having been diagnosed with an upper gastrointestinal haemorrhage, an acute kidney injury, and hypovolaemia.
The hospital pharmacist notified Mr Dawood and Ms A, his employee, of Ms B’s hospitalisation on 27 May 2019. The pharmacist advised that Ms B’s hospitalisation had been a result of her consumption of rivaroxaban. Mr Dawood told the pharmacy staff that he was unable to locate Ms B’s CRC form for the incorrectly dispensed medication.
Following the notification of Ms B’s hospitalisation, Mr Dawood attempted to frame Ms A for his mistake. On 28 May 2019 he entered the pharmacy at 6.53am through the back door, disposed of the original CRC that had been created by Ms C, and printed new CRCs. He backdated these to 3 May 2019, and forged Ms C’s initials in the ‘packed by’ section, and Ms A’s initials in the ‘checked by’ section. He then placed these in a batch of processed CRCs.
Having then ‘found’ the missing CRC for rifaximin later that morning, he advised Ms A that she was the pharmacist who had checked the incorrectly dispensed medication. He escalated the matter to Green Cross Health and the Pharmacy Defence Association and told another pharmacist and Ms B of Ms A’s error.
Ms A was adamant that she had not made the error, and she filed a complaint with the Pharmacy Council regarding the dispensing error and Mr Dawood’s subsequent actions. In response, Mr Dawood admitted that he was the pharmacist who had checked the prescription for rifaximin where rivaroxaban was dispensed instead.
It was an agreed fact that Mr Dawood was the pharmacist who checked the incorrectly dispensed medication, and that he had acted dishonestly after discovering the error. The Tribunal observed that a dispensing or checking error amounted to negligence, as it was a departure from the standards expected of a pharmacist.
The Tribunal did note that Mr Dawood’s checking error on its own did not warrant a disciplinary sanction. The Tribunal acknowledged that in a busy practice, dispensing and checking errors do occur occasionally. Without belittling the experience of Ms B, or in any way condoning or dismissing such an error, the Tribunal was reluctant to find that a dispensing or checking error on its own was sufficiently serious to warrant a disciplinary sanction.
However, the Tribunal considered that Mr Dawood’s subsequent response, in lying about his own involvement and falsely blaming a colleague, took his conduct over the threshold for disciplinary sanction. The Tribunal was in no doubt that the conduct in Particular (2) amounted to malpractice and reached the disciplinary threshold. The Tribunal observed that Mr Dawood’s contrivance not only in attempting to avoid responsibility, but also in setting up a colleague to take the blame, was highly unethical and could be described as ‘despicable’.
In determining penalty, the Tribunal concluded that the dispensing error in itself did not warrant cancellation of registration. However, in conjunction with several acts of dishonesty, the protective purpose of disciplinary proceedings was considered to be vital in this case.
As such, Mr Dawood’s registration was cancelled for two main reasons:
- First, the significant lengths and degree of dishonesty Mr Dawood engaged in, not only to protect himself but to frame his colleague, who was his employee and his supervisor. This was not the first instance of Mr Dawood attempting to cover up for his shortcomings as he had already been put on notice by the Pharmacy Council after a dispensing error in 2013. After completing an audit, the Council decided to review Mr Dawood’s competence and found that he did not meet several competence standards. Mr Dawood was asked to complete a Competence Programme, which he did not do. A further reassessment of Mr Dawood’s practice occurred in 2016, in which the assessor found that Dr Dawood did not follow standard operating procedures and had not satisfied the requirements of the Competence Programme. Therefore, the Council imposed a requirement that Mr Dawood be supervised and work in association with another pharmacist at all times when dispensing medicines.
- Secondly, the Tribunal could not expect the profession or the public to feel protected or reassured by a further attempt at rehabilitation. As noted above, the Council engaged in rehabilitative measures over a period of four to five years with little or no improvement in Mr Dawood’s dispensing practices. The Tribunal found that rehabilitation had not been effective and that Mr Dawood’s obligations under the Act did not require indefinite supervision or mentoring of a colleague whose practices pose a risk of harm to the public. Therefore, the Tribunal considered that a penalty of cancellation was fair and proportionate in the circumstances.
Mr Dawood was also censured, fined, and ordered to pay costs.
The Tribunal’s decisions can be found at:
https://www.hpdt.org.nz/portals/0/1236Phar21514D.pdf https://www.hpdt.org.nz/portals/0/1290Phar21514D.pdf