A pensioner who was registered blind died after a Boots pharmacy supplied him with medication meant for another patient with a similar name, an inquest heard.
RAF veteran Douglas Lamond, 86, received weekly medicine boxes from Boots, which were assembled in branch and contained pills in separate plastic compartments to take on different days.
Mr Lamond had been receiving many different medications for complaints including type 2 diabetes, heart problems and glaucoma.
Detective Superintendent Andrew Smith said it was “very likely” that the medication error “hastened his death”.
There’s, somewhere, a failing in the dispensing process that I would like to see investigated so another family doesn’t have to go through such a traumatic experience
daughter Dianne Moore
He told Monday’s hearing at Suffolk Coroner’s Court in Ipswich that the weekly pack, when opened, contained seven labels in the name of Anthony Lampard, but the label on the outside said Douglas Lamond.
The pack was assembled at the Boots branch in Felixstowe and delivered to Mr Lamond’s home in the town on May 10, 2012. Mr Lamond died on May 12 at Ipswich Hospital after a friend called an ambulance for him.
“He told paramedics he had been short of breath for the last three days and had chest pain,” Mr Smith said.
A pharmacist and dispenser admitted in police interview that they had breached Boots' standard procedures, Mr Smith said.
Dispenser Susan Hazelwood had slit open a compartment of a previously assembled medicine box to add pills that had been requested and then sealed it with sticky tape, the inquest heard.
“She did not check the existing box to check it was in the name of Douglas Lamond,” said Mr Smith.
Pharmacist Mihaela Seceleanu had checked the box for the additional pills, but not for the existing ones.
She said that adding pills to an existing box then resealing it with tape “was common practice within Boots” although it was not part of standard procedure, Mr Smith said.
The Crown Prosecution Service (CPS) said there was insufficient evidence to charge anybody with gross negligence manslaughter.
Following a right to review appeal by Mr Lamond's family, Ms Seceleanu was cautioned under the Medicines Act 1968. This was for having supplied a product that was not of the nature demanded by the purchaser, Mr Smith said.
Widower Mr Lamond was born in Dundee, had served in the RAF as a bomb aimer and navigator but lived alone at the time of his death.
Mr Smith said that Mr Lamond depended on a number of prescription drugs and was “almost totally reliant on health professionals” preparing them for him, especially as he was registered blind.
A police investigation following Mr Lamond’s death did not identify any other “adverse incidents”. The branch of Boots stopped the assembly of medical packs in branch after the incident.
Independent regulator the General Pharmaceutical Council issued advice including the need to ensure a patient’s name and address were displayed clearly on the front of medical packs.
Daughter Dianne Moore said in a statement read to the hearing: “There’s, somewhere, a failing in the dispensing process that I would like to see investigated so another family doesn’t have to go through such a traumatic experience.”
The inquest, which is expected to last up to two weeks, continues.