Crown Alleges Prescription Error Caused Girl’s Death

Press, Volume CIX, Issue 32054, 31 July 1969, Page 26

Crown Alleges Prescription Error Caused Girl’s Death

(New Zealand Press Association)

AUCKLAND, July 30. The trial of a company on a chargeJHknanslaughter began in the Supreme Court at Auckland yesterday. gnß

The firm, Murray Wright, Ltd, chemist, is charged that on March 25 at Auckland it did, by an omission on or about March 13 to perform or observe a legal duty, kill Cornelia Charmaine Keepa, thereby committing manslaughter.

Evidence in the trial was completed today. Counsel will make their final addresses tomorrow and Mr Justice Henry will sum up to the jury. Mr R. K. Davison, Q.C., with him Mr N. W. Thom, appear for the company and Mr D. S. Morris represents the Crown.

For the Crown, Mr D. S. Morris said the charge arose from the death of a teen-age girl who, it was alleged, died from taking tablets dispensed by Murray Wright, Ltd, This was a private company run by Murray Wright, a qualified chemist. Mr Morris said the evidence would be that the prescription given by the doctor was for chloramphenicol, but instead of these tablets she was given chlorpropamide. There would be evidence that taking this particular drug led to a lowering of the sugar content in the blood and and swelling of the brain, leading to death. The Crown alleged it was the: incorrect dispensing that brought about the death and that reasonable care in the method of handling and dispensing drugs was not taken.

The Crown’s contention was that the firm’s methods did not reach the standard required by the law. He said it made no difference that this was a company—it had the same obligations as any other person. A company dealing with drugs had a duty to take reasonable precautions and care so as not to endanger human life. If its actions caused death it was criminally responsible. There would be evidence that an unqualified woman was allowed to handle prescriptions and that this medicine was made up by her. It was not checked. There was no allegation that the chemist or his staff meant this to happen, Mr Morris said.

Dr Douglas McKelvie Jack said he examined the girl on March 11 and found her in the early stages of pregnancy. He referred her to St Helen’s Hospital and prescribed butalgin for a rheumatic condition. On March 13, he called to see her at her home and found her suffering an upper respiratory infection, for which he prescribed an antibiotic, chloramphenicol. On Saturday, March 15, he saw her again and found her in a coma. She had had a convulsion. He diagnosed epilepsy. He called back later because she had more fits. She was still unconscious and he admitted her to Auckland Hospital. On March 16 he spoke to Dr Matthews at the hospital and then got in touch with Mr Wright. He met Mr Wright at the shop, where they found the prescription for chloramphenicol. Mr Wright said that the prescription was clearly for chloramphenicol. INSTRUCTIONS FOLLOWED Teaho Tahere Charles Pomana said he had been living at Kingsland with Cornelia Keepa and her parents in March. On March 11, he took her to the doctor. Two days later-die got Dr Jack to go to the house, where the doctor wrote a prescription. Witness took the prescription to the chemist’s shop, where he gave it to a young girl. On the Saturday morning he could not awaken Cornelia, and she was frothing at the mouth. She had been keeping to the instructions on the bottle of tablets.

PRESCRIPTION QUERIED Joyce Berghan said she had been an assistant at the shop about 13 years. She had no chemist's qualifications. Sometimes when Mr Wright was very busy she might count tablets and type the labels. She was not allowed to handle mixtures, ointments or anything containing a narcotic. If she could not read a prescription, she would ask Mr Wright about it, otherwise she would type a label, put tablets in the bottle, and leave them on the dispensing bench to be checked. In March, 1969, a qualified chemist, Mr Wilson, worked part-time in the shop. On March 13, she picked up a prescription that she could not quite understand. She thought it was for chlorpropamide and asked Mr Wilson, who said it was. She knew the drug was for diabetics but the dosage meant nothing to her. She left the bottle on the dispensing bench on top of the prescription. She. also asked Mr Wilson the initial of the doctor, because she could not read it. To Mr Davison, she said she had been allowed to put tablets in bottles for about four years. If she was in any doubt about what was wanted, she would always ask one of the trained chemists. When she queried Miss Keepa’s prescription with Mr Wilson she held it up to him; He did not take it and read it.

She said that when bottles were checked, they were moved from the dispensing bench to another shelf nearer the shop. “MASSIVE OVERDOSE” Ray Roberts Wilson, a registered pharmacist, said he worked for Murray Wright on Thursdays. He did not recall seeing this prescription on March 13. He said there was a practice of telephoning the prescriber if there was any doubt about a prescription. If the prescription had been for chlorpropamide it would have been a massive overdose, and if he had seen such a dosage he would have telephoned the doctor immediately. To Mr Davison, Mr Wilson said that any work done by

iah Berghan was to be i cMteked by a qualified disi penser. . Mr Davison: Have you no s recollection at all of seeing - the prescription that day?— - No. , CAUSE OF DEATH 1 Dr Francis John Cairns r said he conducted a post-mor-r tem examination of Miss . Keepa. He considered death was caused by acute swelling > of the brain, and from his r reading of the hospital notes . he considered this was a resuit of prolonged low bloodr sugar level. . Dr Cairns agreed that the s taking of the drug chlorpro- > pamide could bring this about. He said he believed j Miss Keepa was to take two 1 tablets four times daily. The i amount in each tablet was 250 r milligrams, which he thought > was the maximum dose in one i day. This meant she was takr ing eight times the maximum . dose. DEFENCE CASE In his opening address for ) the defence, Mr Davison said h the company was not trying a to escape any responsibility a it might have. a The jury was there to de- < cide whether there was any s legal responsibility on the o company for what happened. In the circumstances of the case the company was really o Mr Wright. He was managing e director. Mr Davison said the come pany could be guilty only if i, Mr Wright was the one who e dispensed the prescription (and this was not suggested), o if he failed to take reasonable B precautions on how dispensing was done, or if he failed to lay down a proper system. . The defence said that not--1 withstanding what happened ? the company had laid down ’ a method of prescribing £ which, if followed, provided , a reasonably safe method. 1 What had happened was ' that one or other of the 5 employees, or both, had let r the system down. Either Mr ' Wilson did not check or Mrs Berghan gave the tablets out “ without their being checked. , If the jury found this was J so the company would not be J responsible, he said. j COMPANY’S SYSTEM i Giving evidence, Murray 1 Moncrieff Wright said he quai lifted as a pharmacist about i 20 years ago. He bought the a business in 1960, and made 1 it a limited liability company, b with his wife and himself as i- shareholders. i, Mfs Berghan had been at the shop for 13 years. Mr r Wilson was employed on a e casual basis and was there almost every Thursday to run

the pharmacy while witness did other duties. When a customer brought in a prescription it would be handed to any of the staff, who would normally ask for it to be endorsed. It would then be brought ; into the dispensary, where the assistants would refer it to ! witness, or to Mr Wilson, to see if there were sufficient ; ingredients and how long it ■ would take to dispense. It ; would then be put on a file . and taken off as it came due. The dispenser would take it and normally type the i label, then go back to the . dispensing bench and fulfil i it. If Mrs Berghan had anyI thing to do with it she would i leave the completed articles :on the prescription to be i checked. After checking it : would be placed on the out- : side shelf.