When the mother of a nine-year-old girl was told that she had given her daughter a heroin substitute instead of antibiotics, her first reaction was to rush her to hospital where doctors said she could have died if given further doses.

“It is still in my head about what if we gave her more. We would have lost her,” said Donna Buckley, the distraught mother, and shuddered to think that the wrong drug could have been potentially deadly.

Ruby-Mai Bell had a water infection and her mother had taken her to their local GP at the Manor Pharmacy in Nottingham, where they were given someone else’s medication instead.

Pharmacist visited to inform of error

Not realising the mistake, Buckley, a care-assistant, gave Ruby two spoonfuls of the medicine but stopped after the first dose as she noticed that her nine-year-old daughter appeared drowsy.

“Ruby went upstairs to lie down and I went to check on her later and she was really sleepy. I noticed her eyes were rolling around and I thought I would not give her any more medicine,” Buckley said.

Just then, a pharmacist appeared at her door to inform her of the medication error but assured her that Ruby would be fine. He had also requested for a private meeting with the family at the pharmacy the next day. But later that day, Buckley and Ralph Bell, Ruby’s father, returned to the pharmacy when Ruby felt “really warm” and her condition worsened.

They were then sent home and told that Ruby had been given methadone by mistake.

“I was hysterical. The state I was in was unreal. I thought I was going to lose my daughter when I heard that word, methadone,” said Buckley.

The next two spoonfuls could have been deadly

The couple then quickly brought Ruby to the A&E at Queen's Medical Centre where they carried out a series of tests on her and monitored her condition overnight.

“The worst thing was the doctors saying to me that if I’d have given her those next two spoonfuls it would be completely different,” said Buckley.

It was a close shave but nevertheless, Ruby made a full recovery and is back at school though the experience had left her feeling negative about medicine.

Ruby said, “I am scared to take medicine now because I took the wrong medicine and it made me really poorly.”

Her parents are considering legal action against the pharmacy.

Ongoing investigation of prescription mix-up

Matt Goode, a lawyer for ABR Solicitors, said, “I have never heard of anything like this before. It is more startling because methadone is used for people with a heroin addiction.”

He explained that methadone is usually administered to the patient directly in the pharmacy.

“The fact that these parents have been given the whole bottle of methadone is horrendous. It is just madness. You have given a child a Class A drug.”

Following the incident, NHS England has started investigating on the erroneous dispensing, and Manor Pharmacy has written to the family, apologising and explaining the mix-up.

In the letter, the pharmacy stated, “I would like to begin by apologising on behalf of the company for the distress and inconvenience this incident has caused Ruby-Mai and yourselves.”

They had also given assurance that such incidents would be taken seriously and investigated in full, while taking steps to minimise the risk of future incidents. The police are investigating the incident under local authority child protection procedures. MIMS

Read more:
Hospital given steep fine for lack of security in medications
Pharmacists play crucial role in reducing medication errors
Doctors' bad handwriting puts patients at risk

Sources:
https://www.thesun.co.uk/news/2839990/nine-year-old-girl-rushed-to-hospital-after-bungling-pharmacist-gave-her-methadone-instead-of-antibiotics/
http://metro.co.uk/2017/02/11/pharmacist-gives-9-year-old-class-a-drug-instead-of-antibiotics-6441538/
http://www.nottinghampost.com/nine-year-old-girl-mistakenly-given-heroin-substitute-methadone-by-pharmacist/story-30127113-detail/story.html