0:00:06 > 0:00:08A trusted household name...
0:00:10 > 0:00:14..a family firm that began by selling herbal remedies in Nottingham, is now
0:00:14 > 0:00:21part of a global business providing a crucial NHS service in an industry under pressure.
0:00:22 > 0:00:25And some Boots pharmacists are worried.
0:00:25 > 0:00:28I feel it's really, really imperative and critical that the public are
0:00:28 > 0:00:30aware of what's going on.
0:00:30 > 0:00:33Some days, you would easily describe the team as being at breaking point.
0:00:34 > 0:00:39Patient safety is the most important thing to me and to our pharmacists.
0:00:39 > 0:00:42When mistakes are made, patients can die.
0:00:42 > 0:00:45We're talking about people's lives here, and in my case,
0:00:45 > 0:00:48my mum, without question, accepted what she was given,
0:00:48 > 0:00:49and yet that system failed.
0:00:51 > 0:00:57Now, for the first time, a former manager has decided to go public.
0:00:57 > 0:01:00Pharmacists are working extremely hard to protect patients,
0:01:00 > 0:01:04but they're really stretched trying to keep patients safe.
0:01:04 > 0:01:09Are pharmacists at the UK's biggest pharmacy chain under too much pressure?
0:01:18 > 0:01:24Dianne Moore has spent the last five years fighting for justice for her father.
0:01:27 > 0:01:29In May 2012,
0:01:29 > 0:01:34Douglas Lamond died after he was given medication meant for someone else.
0:01:35 > 0:01:42The 86-year-old RAF veteran had a heart condition and was registered as blind.
0:01:42 > 0:01:46He had trust that they would give him the right tablets.
0:01:46 > 0:01:51He would never have dreamt that the wrong tablets would have been sent out.
0:01:54 > 0:02:00Suffolk Police allowed us to film the tablets Douglas was taking before he died.
0:02:00 > 0:02:04They were delivered by his local Boots pharmacy in this pack -
0:02:04 > 0:02:08a dosette box designed to make it easier for him to take medicine at
0:02:08 > 0:02:10the right time.
0:02:13 > 0:02:16On the outside is Douglas Lamond's name.
0:02:16 > 0:02:20But on the inside, the prescriptions are for a Mr Lampard.
0:02:22 > 0:02:26Douglas took more than 30 of Mr Lampard's tablets,
0:02:26 > 0:02:30including medication to reduce blood sugar levels, which he didn't need.
0:02:34 > 0:02:39To witness him going into heart failure and then to subsequent
0:02:39 > 0:02:42cardiac arrest -
0:02:42 > 0:02:45it's the most devastating and horrible thing to see.
0:02:48 > 0:02:52This is the pharmacy in Felixstowe where the mistake was made.
0:02:52 > 0:02:54An error so serious,
0:02:54 > 0:02:58Suffolk Police considered a charge of corporate manslaughter.
0:02:58 > 0:03:02Staff hadn't followed company safety procedures.
0:03:02 > 0:03:04I felt angry.
0:03:04 > 0:03:10I felt I wanted to throw a brick through every single Boots store that I saw.
0:03:10 > 0:03:11I blame Boots for...
0:03:13 > 0:03:14..for my father's death.
0:03:17 > 0:03:19In 2011,
0:03:19 > 0:03:24one manager had been concerned about pressure in Boots pharmacies.
0:03:25 > 0:03:29Greg Lawton reported to the superintendent pharmacist at Boots headquarters.
0:03:29 > 0:03:32As a clinical governance pharmacist,
0:03:32 > 0:03:36he thought the company wasn't giving pharmacies enough money for staff.
0:03:36 > 0:03:40This is the first time he's spoken publicly.
0:03:40 > 0:03:45When I came into the patient safety role in 2011,
0:03:45 > 0:03:50I wrote a paper for the superintendent's office, which set out those concerns,
0:03:50 > 0:03:55explained the issues with the staffing model and how that could
0:03:55 > 0:03:57put patient safety at risk.
0:04:01 > 0:04:05In 2012, in the same month as Douglas's death,
0:04:05 > 0:04:09police investigated another serious dispensing error.
0:04:09 > 0:04:15The Boots UK board ordered an urgent investigation into more than 100 stores
0:04:15 > 0:04:17with the highest level of incidents.
0:04:17 > 0:04:20Greg Lawton was looking at the North region.
0:04:20 > 0:04:24We spoke to pharmacists, to store managers and to area managers,
0:04:24 > 0:04:26and what those people were saying,
0:04:26 > 0:04:31absolutely, staffing levels was flagged as an issue - poor staffing levels.
0:04:31 > 0:04:34There were issues with training that were identified,
0:04:34 > 0:04:37there were issues with the premises that were identified.
0:04:37 > 0:04:40The company told us that, after the investigation,
0:04:40 > 0:04:43it implemented a detailed action plan.
0:04:43 > 0:04:47It then commissioned academic research which, it says, found that pharmacies
0:04:47 > 0:04:52with higher levels of dispensing staff were associated with higher error rates.
0:04:56 > 0:05:01Deaths following dispensing errors are extremely rare.
0:05:01 > 0:05:03But six months after Douglas,
0:05:03 > 0:05:08Arlene Devereaux died following a massive morphine overdose.
0:05:08 > 0:05:11It was her 71st birthday.
0:05:11 > 0:05:13She had osteoporosis.
0:05:13 > 0:05:16Even her hands were painful, you know,
0:05:16 > 0:05:18so that's why she was on Zomorph.
0:05:18 > 0:05:23This time, a Boots pharmacy at Chesterfield, in Derbyshire, dispensed
0:05:23 > 0:05:28six times the strength of morphine tablets prescribed by Arlene's GP.
0:05:31 > 0:05:35The coroner concluded that Arlene's death was accidental and there were
0:05:35 > 0:05:39clear opportunities for the error to be corrected.
0:05:39 > 0:05:42The pharmacist in charge said he must have been interrupted.
0:05:42 > 0:05:44We don't know why.
0:05:44 > 0:05:49It was shocking, and it kind of reminded you of the importance of the job
0:05:49 > 0:05:54that you were doing and strengthened your resolve to try and make a difference.
0:05:58 > 0:06:00So what are the risks?
0:06:00 > 0:06:04Boots told us it dispensed more than 220 million prescription items
0:06:04 > 0:06:06in a year.
0:06:06 > 0:06:08There were just over 900 reported incidents
0:06:08 > 0:06:11where patients were harmed in some way.
0:06:11 > 0:06:14That ranged from needing minor treatment to permanent damage.
0:06:14 > 0:06:19So, statistically, that kind of incident is very, very rare.
0:06:19 > 0:06:22And some might not have been the pharmacy's fault.
0:06:23 > 0:06:26Boots says, compared to other pharmacy chains,
0:06:26 > 0:06:29it has one of the lowest levels of harm
0:06:29 > 0:06:32and an industry-leading approach to patient safety.
0:06:35 > 0:06:39The Pharmacists' Defence Association Union is the largest union
0:06:39 > 0:06:43representing the profession, with 25,000 members.
0:06:43 > 0:06:47Mark Pitt worked as a Boots pharmacist for 20 years.
0:06:47 > 0:06:51The PDAU supports a third of Boots' 6,500 pharmacists
0:06:51 > 0:06:55and is involved in a legal battle to be recognised as a union there.
0:06:56 > 0:06:58Pharmacists have told us, working for Boots,
0:06:58 > 0:07:00that they're finding that,
0:07:00 > 0:07:04increasingly, there are less staff available,
0:07:04 > 0:07:07and that makes their job a lot more difficult
0:07:07 > 0:07:08and more pressurised.
0:07:08 > 0:07:13They are concerned about speaking up about problems in the workplace
0:07:13 > 0:07:17because they fear the consequences of what will happen to them.
0:07:18 > 0:07:23Boots UK pharmacy director is a qualified pharmacist who's worked
0:07:23 > 0:07:25for the company for 20 years.
0:07:25 > 0:07:28He spends a day a week out in its stores.
0:07:29 > 0:07:30That's just not something I recognise.
0:07:30 > 0:07:33I personally have been able to raise whatever I've needed, whenever.
0:07:33 > 0:07:36I know we have an open and honest culture.
0:07:36 > 0:07:38If they fear speaking up, they can ring me direct,
0:07:38 > 0:07:40I absolutely assure confidentiality on that,
0:07:40 > 0:07:42just like we do for our whistle-blowing hotline.
0:07:42 > 0:07:44They have a responsibility themselves as a pharmacist and
0:07:44 > 0:07:47a professional to speak up.
0:07:47 > 0:07:50The union says that many pharmacists it represents at Boots
0:07:50 > 0:07:52are too frightened to speak out.
0:07:52 > 0:07:54They're scared they'll lose their jobs.
0:07:54 > 0:07:59But two were prepared to be interviewed, as long as we protected their identity.
0:08:02 > 0:08:05Actors are speaking their words.
0:08:05 > 0:08:09Some days, you would easily describe the team as being at breaking point.
0:08:09 > 0:08:12That's because simply the amount of work that has to be done,
0:08:12 > 0:08:14can't physically get done safely,
0:08:14 > 0:08:18and it can't physically get done without either working longer hours
0:08:18 > 0:08:20or working after the store's closed.
0:08:25 > 0:08:26Mistakes may not be picked up on,
0:08:26 > 0:08:30and that could ultimately lead to somebody possibly dying.
0:08:30 > 0:08:35Somebody missing medication, harm coming to people, small mix-ups, really,
0:08:35 > 0:08:37just one tablet for another tablet.
0:08:42 > 0:08:45In September 2013,
0:08:45 > 0:08:50Boots told its pharmacists about two very serious dispensing errors in six days.
0:08:50 > 0:08:54They were warned not to cut corners with company procedures.
0:08:58 > 0:09:01Two months later, there was another death.
0:09:02 > 0:09:04To find out what happened,
0:09:04 > 0:09:07I'm heading to the small Highland town of Kingussie.
0:09:09 > 0:09:13Margaret Forrest trusted her local Boots to supply the daily medicine
0:09:13 > 0:09:19she needed. Instead, Mrs Forrest, an active and independent 86-year-old,
0:09:19 > 0:09:22was given a Mrs Frost's diabetes tablets.
0:09:26 > 0:09:29She had total belief in the system.
0:09:29 > 0:09:34She would have taken medicine given to her in total confidence that that
0:09:34 > 0:09:38was the right medicine that she had to take to protect herself -
0:09:38 > 0:09:39and it didn't.
0:09:39 > 0:09:41At the end of the day, we all know human error.
0:09:41 > 0:09:44We all make mistakes, we all do,
0:09:44 > 0:09:46but unfortunately some mistakes are very tragic ones,
0:09:46 > 0:09:48and this was the case with my mother.
0:09:50 > 0:09:53Just like the cases of Douglas and Arlene,
0:09:53 > 0:09:57company safety procedures hadn't been followed in Kingussie.
0:09:57 > 0:10:01Understaffing wasn't found to have contributed to any of the deaths.
0:10:01 > 0:10:04One mistake like this is one mistake too many,
0:10:04 > 0:10:08and my absolute assurance is, despite having our industry-leading record,
0:10:08 > 0:10:13we will continue...continue to focus on minimising the chances of it happening again.
0:10:15 > 0:10:19Boots told us there have been no further deaths linked to dispensing
0:10:19 > 0:10:23errors at its pharmacies since Mrs Forrest died.
0:10:23 > 0:10:25Greg Lawton wasn't investigating the deaths,
0:10:25 > 0:10:29but he'd been looking in detail at staffing and budgets
0:10:29 > 0:10:33and was concerned that pressure from understaffing in Boots pharmacies
0:10:33 > 0:10:36could lead to serious mistakes.
0:10:36 > 0:10:40He told a senior patient-safety boss at company headquarters
0:10:40 > 0:10:42just how worried he was.
0:10:42 > 0:10:46I told her that I was terrified that something bad might
0:10:46 > 0:10:49happen to a patient, and the patient might be seriously harmed or
0:10:49 > 0:10:51a patient might die
0:10:51 > 0:10:56because of the inadequate staffing levels and the pressure that was
0:10:56 > 0:10:59placed on pharmacists and pharmacy teams.
0:11:01 > 0:11:05Greg Lawton thought the way the company calculated how many staff it
0:11:05 > 0:11:08needed was fundamentally flawed.
0:11:08 > 0:11:09A few weeks later,
0:11:09 > 0:11:14he told management he was considering going to the pharmacy regulator.
0:11:14 > 0:11:20The information that I had and the things that I knew about the...
0:11:21 > 0:11:25..staffing levels, I think that that was the biggest risk to patient safety
0:11:25 > 0:11:28that I'd come across within the company.
0:11:29 > 0:11:34His concerns were immediately escalated to the highest level with the Boots board,
0:11:34 > 0:11:39and he was invited to take part in ongoing work on staffing.
0:11:39 > 0:11:41So, what's supposed to keep patients safe?
0:11:41 > 0:11:44Well, as far as enforcing safe staffing goes,
0:11:44 > 0:11:47the only legal requirement is that, when a pharmacy is open,
0:11:47 > 0:11:51the pharmacist in charge, the responsible pharmacist, has to be there.
0:11:54 > 0:11:58All pharmacy companies must set their own safety rules, called
0:11:58 > 0:12:00standard operating procedures.
0:12:00 > 0:12:04They're there to protect patients' safety, and staff should follow them.
0:12:04 > 0:12:08But Boots pharmacists we've talked to say time pressures mean they
0:12:08 > 0:12:10sometimes take shortcuts.
0:12:11 > 0:12:13You don't have the correct amount of time.
0:12:13 > 0:12:16You don't even have the correct amount of staff to do things on time.
0:12:16 > 0:12:17The staffing thing is huge.
0:12:17 > 0:12:21At best, you'll barely have enough staff to just cope.
0:12:21 > 0:12:26We have standard operating procedures in place for all of our operational procedures
0:12:26 > 0:12:28and our dispensing process in Boots.
0:12:28 > 0:12:32They're recognised as being really high-quality, industry-leading.
0:12:32 > 0:12:36A lot of work has gone in to finding the processes that minimise the risk
0:12:36 > 0:12:39to our patients. Nobody should ever be in a position,
0:12:39 > 0:12:42and nobody should ever take the choice, to take any kind of shortcut.
0:12:43 > 0:12:49Comments on Boots' own Pharmacy Unscripted staff website in 2017,
0:12:49 > 0:12:53also show how concerned some pharmacy staff are.
0:12:53 > 0:12:56Pharmacists at Boots do an excellent job, but often in very,
0:12:56 > 0:12:58very difficult circumstances.
0:12:58 > 0:13:03And considering it's the largest pharmacy company in America and Europe...
0:13:05 > 0:13:06..it shouldn't be like that.
0:13:07 > 0:13:12Boots told us its own survey suggests four in five pharmacists were either
0:13:12 > 0:13:14comfortable or neutral about their workload,
0:13:14 > 0:13:17which is better than the rest of the NHS.
0:13:18 > 0:13:21The pharmacy regulator, the General Pharmaceutical Council,
0:13:21 > 0:13:28told us it's inspected more than 2,000 Boots pharmacies since November 2013.
0:13:28 > 0:13:3426 didn't have enough qualified and skilled staff to provide a safe service.
0:13:34 > 0:13:37It says they're now up to standard.
0:13:37 > 0:13:42That means only 1.2% of Boots pharmacies failed on the staffing standard,
0:13:42 > 0:13:45which compares favourably with all other pharmacies.
0:13:45 > 0:13:49I'm absolutely confident that the resource is there to deliver the patient care.
0:13:49 > 0:13:51I am confident that we have enough staff.
0:13:54 > 0:13:59Community pharmacy is part of the NHS, and its funding is being cut.
0:13:59 > 0:14:03More prescriptions are being dispensed than ever before -
0:14:03 > 0:14:04more than 1 billion a year.
0:14:04 > 0:14:08And as the population gets older, they're becoming more complex.
0:14:10 > 0:14:14I think my record is 37 medicines that they're on,
0:14:14 > 0:14:17and you have to check each one for suitability.
0:14:17 > 0:14:19You're trying to do that in a busy, hectic environment,
0:14:19 > 0:14:22and you've got all the other tasks to do.
0:14:22 > 0:14:24Accuracy is crucial.
0:14:24 > 0:14:29Boots says pharmacists should only check their own work as a last resort.
0:14:32 > 0:14:35But the pharmacists we spoke to told us, in their experience,
0:14:35 > 0:14:38when they're busy, that doesn't always happen.
0:14:38 > 0:14:41Often, you end up having to self-check medication.
0:14:41 > 0:14:44Often, you're in a situation where you've got no staff at all
0:14:44 > 0:14:47and you're having to dispense medication and then self-check that medication.
0:14:47 > 0:14:48Every day,
0:14:48 > 0:14:52there'll be an occasion where I've got to self-check on all of
0:14:52 > 0:14:53the shifts that I work.
0:14:53 > 0:14:56All our prescriptions are checked twice before they go out.
0:14:56 > 0:14:58Less than 1% of the time,
0:14:58 > 0:15:00and 1% of the prescriptions that we dispense,
0:15:00 > 0:15:04a pharmacist will return to their own work and check that prescription themselves.
0:15:04 > 0:15:07If we have pharmacists who think they're in situations where
0:15:07 > 0:15:10they are having to do that when they shouldn't, they must,
0:15:10 > 0:15:13they have a professional responsibility to raise that.
0:15:15 > 0:15:19If the pharmacist in charge thinks their pharmacy is unsafe,
0:15:19 > 0:15:23one option they have is to temporarily close.
0:15:23 > 0:15:27In a union survey of more than 400 Boots pharmacists,
0:15:27 > 0:15:3131 said they'd closed pharmacies because they'd been concerned
0:15:31 > 0:15:34about patient safety. More worryingly,
0:15:34 > 0:15:39160 out of 212, who'd considered it, said they didn't close because they
0:15:39 > 0:15:43didn't believe their decision would be supported.
0:15:43 > 0:15:46You end up staying open in these unsafe situations
0:15:46 > 0:15:50and, out of your own goodwill, try to catch up on, maybe, backlogs
0:15:50 > 0:15:52or try to reorganise things.
0:15:52 > 0:15:56160 is a very small sample, but it's an important sample.
0:15:56 > 0:15:58If we have got people who genuinely feel like that,
0:15:58 > 0:16:00then it does concern me, so please, please,
0:16:00 > 0:16:04please do come and speak to me and give me the chance to sort it out.
0:16:04 > 0:16:06This is a very, very extreme circumstance.
0:16:06 > 0:16:09We will always support a local shop, whether that's with resource,
0:16:09 > 0:16:11whether that's with time, to be able to stay open.
0:16:12 > 0:16:18So how do pharmacies decide how many staff they need to keep patients safe?
0:16:18 > 0:16:21There's no regulation to say, if you dispense this many prescriptions,
0:16:21 > 0:16:23you have to have this many staff.
0:16:23 > 0:16:25To calculate the workload,
0:16:25 > 0:16:29Boots uses a complex model, which includes the time it takes to
0:16:29 > 0:16:31dispense various prescriptions.
0:16:35 > 0:16:38In July 2014,
0:16:38 > 0:16:43Greg Lawton was asked to be part of a team which recalculated those times.
0:16:43 > 0:16:47The work that we did on time standards was regarded as very robust work.
0:16:47 > 0:16:51It was done alongside external consultants,
0:16:51 > 0:16:56and they called it world-leading.
0:16:56 > 0:17:00The team reported back that Boots needed to spend tens of millions
0:17:00 > 0:17:02more on its pharmacies.
0:17:02 > 0:17:06We calculated the amount of investment from the time standards
0:17:06 > 0:17:10and from other operational considerations
0:17:10 > 0:17:13and to meet the expectations that the company had of pharmacy staff
0:17:13 > 0:17:19and its stores, and that was in excess of £100 million additional
0:17:19 > 0:17:21investment every year - that was required to fund that.
0:17:24 > 0:17:27Boots says that only Greg Lawton held the view that in excess of
0:17:27 > 0:17:30£100 million a year was required.
0:17:31 > 0:17:35The company told us it did make significant additional investment in
0:17:35 > 0:17:37pharmacies following the time standards review,
0:17:37 > 0:17:41but says the specific figure is commercially sensitive.
0:17:41 > 0:17:46Greg - his opinions and his concerns - left the business over
0:17:46 > 0:17:49two years ago and aren't relevant to Boots today.
0:17:49 > 0:17:51We continue to invest in more people,
0:17:51 > 0:17:52more pharmacists, than ever before.
0:17:52 > 0:17:55That's into our shops and it's into our processes,
0:17:55 > 0:17:57helping to make things more safe.
0:17:59 > 0:18:01As the UK's biggest pharmacy chain,
0:18:01 > 0:18:05Boots is providing a crucial NHS service.
0:18:05 > 0:18:09We asked the company to explain exactly how it works out how many
0:18:09 > 0:18:13staff to put in almost 2,400 pharmacies.
0:18:13 > 0:18:14It refused.
0:18:17 > 0:18:21The company told us the time standards, which are part of the calculation,
0:18:21 > 0:18:25are a trade secret which could be copied by its competitors.
0:18:25 > 0:18:28Lloyds, the UK's second largest pharmacy chain,
0:18:28 > 0:18:33has provided both its time standards and how they're used to work out staffing levels.
0:18:35 > 0:18:38Boots says you can't compare one company with another,
0:18:38 > 0:18:43and it shares the principles of how it works out staffing budgets with line managers.
0:18:45 > 0:18:50Joy Wingfield is a pharmacy law and ethics expert who's trained the last
0:18:50 > 0:18:56two Boots superintendents - the pharmacists in charge of patient safety.
0:18:56 > 0:18:59I don't really accept that they are trade secrets.
0:19:02 > 0:19:05If they're confident that their staffing calculations do maintain
0:19:05 > 0:19:09patient safety, I don't see why they should be unhappy to share them.
0:19:13 > 0:19:16In May 2016, in Scotland,
0:19:16 > 0:19:20Steven Forrest represented his family at the fatal accident inquiry
0:19:20 > 0:19:21into his mother's death.
0:19:21 > 0:19:25He wanted to know what happened before the prescription was handed over.
0:19:25 > 0:19:29The pharmacist in charge exercised her right not to appear.
0:19:29 > 0:19:33Instead, her witness statement was read out.
0:19:33 > 0:19:35The mere fact that that is not...
0:19:35 > 0:19:40We didn't have the opportunity to talk to the pharmacist about that,
0:19:40 > 0:19:44to find out what her views were on that, was very, very alarming to us.
0:19:44 > 0:19:47That was a key, key witness.
0:19:47 > 0:19:51But Steven did cross-examine other members of staff.
0:19:51 > 0:19:54The fatal accident inquiry heard that shortcuts were taken if they
0:19:54 > 0:19:57were too busy or tired.
0:19:57 > 0:19:59In the court, as the evidence presented by the pharmacy staff
0:19:59 > 0:20:02themselves that were operating, that were understaffed...
0:20:02 > 0:20:04At least two of the staff weren't...
0:20:05 > 0:20:08..there - one was on honeymoon and one was off sick.
0:20:09 > 0:20:13The sheriff concluded the pharmacy was quiet at the time
0:20:13 > 0:20:15and understaffing didn't play a part.
0:20:15 > 0:20:18A member of staff hadn't followed company procedures.
0:20:18 > 0:20:23The name and address hadn't been checked when the tablets were handed over.
0:20:23 > 0:20:26There was no defect in the actual system of working.
0:20:26 > 0:20:30Margaret Forrest's death was caused by human error.
0:20:30 > 0:20:33It's all very well saying, we have standard operating procedures,
0:20:33 > 0:20:36but, if they're not being followed and you're not addressing why
0:20:36 > 0:20:40they're not being followed, these incidents will continue to happen.
0:20:40 > 0:20:43Staff at Kingussie were given refresher training.
0:20:43 > 0:20:46In a personal injury claim by the family,
0:20:46 > 0:20:52Boots UK admitted vicarious liability for the negligence of one of its staff.
0:20:56 > 0:21:00Last March, the inquest into Douglas Lamond's death was held in Suffolk.
0:21:00 > 0:21:04Staff told the coroner on the day the prescription went out, they'd been
0:21:04 > 0:21:06very busy and under pressure.
0:21:06 > 0:21:11They said they'd kept telling their area manager they didn't have enough space to do their job.
0:21:11 > 0:21:14The police report said that meant they weren't following the company's
0:21:14 > 0:21:16standard operating procedures.
0:21:16 > 0:21:20The coroner said they were operating in a difficult situation.
0:21:24 > 0:21:29Boots told us it found no record of staff raising concerns with the manager.
0:21:29 > 0:21:33The pharmacist in Felixstowe was eventually given a police caution
0:21:33 > 0:21:35for an offence under the Medicines Act.
0:21:38 > 0:21:42When detectives in Suffolk investigated Douglas's death,
0:21:42 > 0:21:45they wanted to see Boots' own internal investigation report.
0:21:45 > 0:21:50The company was entitled to refuse under legal professional privilege.
0:21:52 > 0:21:55While the detective in charge acknowledges that,
0:21:55 > 0:21:58he feels the company had a moral responsibility.
0:21:59 > 0:22:01Do I feel that Boots gave us the full cooperation?
0:22:01 > 0:22:03No, I don't.
0:22:03 > 0:22:06I do think, particularly a big corporate company such as Boots,
0:22:06 > 0:22:09who have a significant responsibility towards public safety,
0:22:09 > 0:22:14have a moral duty to cooperate fully with any police investigation.
0:22:14 > 0:22:16And also they have an overriding duty
0:22:16 > 0:22:19to demonstrate transparency to the family.
0:22:19 > 0:22:23Boots says it cooperated fully with the police, and legal privilege
0:22:23 > 0:22:27allows staff to make full and frank reports.
0:22:27 > 0:22:31The company says it wishes to apologise again to the families of the three patients
0:22:31 > 0:22:33who died following dispensing errors.
0:22:37 > 0:22:40We wanted to find out how many errors there are in community pharmacy,
0:22:40 > 0:22:42but it hasn't been easy.
0:22:42 > 0:22:43We do know that, in a year,
0:22:43 > 0:22:48more than 17,000 incidents involving medication were reported to the NHS
0:22:48 > 0:22:50across the industry.
0:22:50 > 0:22:53But that reporting's voluntary, so the real figure could be higher.
0:22:56 > 0:22:59A new law has gone before Parliament.
0:22:59 > 0:23:03It's hoped it'll encourage pharmacists to report more errors,
0:23:03 > 0:23:04so that lessons can be learned.
0:23:07 > 0:23:12In September 2014, at Boots UK headquarters,
0:23:12 > 0:23:15Greg Lawton was on the verge of going to the regulator.
0:23:17 > 0:23:19He wanted senior management to go with him.
0:23:21 > 0:23:25He had a crucial meeting with the then superintendent pharmacist who
0:23:25 > 0:23:31was the head of patient safety and the director of stores for Boots UK at the time.
0:23:31 > 0:23:36That was the most difficult point in my career, I would say.
0:23:36 > 0:23:40Very difficult. It's like a weight that you would carry with you all of
0:23:40 > 0:23:44the time - that would never leave you, even outside of work.
0:23:46 > 0:23:48And, um...
0:23:50 > 0:23:52Sorry, if we could just pause for a minute,
0:23:52 > 0:23:54I'd appreciate that.
0:23:57 > 0:23:58The superintendent told me that...
0:24:00 > 0:24:02..he felt that nobody...
0:24:04 > 0:24:07..out there would welcome the conversation.
0:24:07 > 0:24:10Knowing that all that I had done was to try to protect patients,
0:24:10 > 0:24:12that was very difficult.
0:24:16 > 0:24:21Boots says the superintendent pharmacist never attempted to dissuade Mr Lawton
0:24:21 > 0:24:24or any member of staff from whistleblowing,
0:24:24 > 0:24:25and he was supported throughout.
0:24:29 > 0:24:35It took another six months, but Greg Lawton DID become a whistleblower.
0:24:35 > 0:24:38He met the GPhC to discuss his concerns.
0:24:43 > 0:24:44I felt a sense of relief
0:24:44 > 0:24:48because I felt that finally somebody would be able to do something about it.
0:24:48 > 0:24:51The GPhC was aware the troops would be coming
0:24:51 > 0:24:54and the company would be investigated.
0:24:54 > 0:24:57Shortly afterwards, Greg Lawton resigned.
0:25:00 > 0:25:05He eventually presented the regulator with a 55-page witness statement and
0:25:05 > 0:25:08dozens of supporting documents.
0:25:08 > 0:25:13He shared his detailed evidence with the Pharmacists' Defence Association Union,
0:25:13 > 0:25:14who he's been working for.
0:25:22 > 0:25:24Since September 2015,
0:25:24 > 0:25:29Boots says it's increased the number of pharmacists by 430.
0:25:29 > 0:25:33Pharmacy technicians have gone up by more than 360.
0:25:33 > 0:25:38Staff with pharmacy capability has risen by more than 2,400.
0:25:38 > 0:25:42Those last two groups include staff in training.
0:25:42 > 0:25:46The company agrees there's been an increase in pharmacists' workload,
0:25:46 > 0:25:49but says it's been fully funded.
0:25:49 > 0:25:51In December 2016,
0:25:51 > 0:25:54the Department of Health began cutting NHS funding
0:25:54 > 0:25:55for community pharmacy.
0:25:55 > 0:26:00By March, budgets will have fallen by more than £200 million.
0:26:00 > 0:26:04The owners of LloydsPharmacy announced, as a result, they're
0:26:04 > 0:26:05closing almost 200 stores.
0:26:09 > 0:26:12Also in December 2016,
0:26:12 > 0:26:16the General Pharmaceutical Council responded to Greg Lawton's evidence.
0:26:16 > 0:26:20It recognised the very difficult position he was in and said his
0:26:20 > 0:26:22information was invaluable.
0:26:22 > 0:26:26But for Greg Lawton, the response was a huge disappointment.
0:26:27 > 0:26:32They told me that they were going to review their inspection model as a result.
0:26:32 > 0:26:35They didn't interview a single person,
0:26:35 > 0:26:38and they concluded that there wasn't any problem at all.
0:26:38 > 0:26:43The GPhC told us it conducted a thorough investigation looking into
0:26:43 > 0:26:48both Mr Lawton's concerns and evidence from Boots' senior management.
0:26:48 > 0:26:52It concluded there wasn't sufficient evidence to suggest a risk to patient safety
0:26:52 > 0:26:57across the organisation, and understaffing was not systemic.
0:26:57 > 0:27:02However, it told us the information provided by Mr Lawton assists them
0:27:02 > 0:27:05when inspecting Boots pharmacies.
0:27:05 > 0:27:07The regulation around pharmacy is inadequate.
0:27:07 > 0:27:12We need regulatory standards to specify what the staffing levels
0:27:12 > 0:27:13must be in pharmacies.
0:27:14 > 0:27:18I agree with that. The idea that staffing levels are too difficult to
0:27:18 > 0:27:21set and don't allow sufficient flexibility -
0:27:21 > 0:27:23it's about time that was challenged.
0:27:23 > 0:27:28I'd like to see the powers they have against corporate employers re-examined,
0:27:28 > 0:27:32and I don't think that anybody could have envisaged that
0:27:32 > 0:27:36the employment of pharmacists would devolve on such enormous,
0:27:36 > 0:27:38large international companies.
0:27:42 > 0:27:47The regulator told us pharmacy owners are best placed to set staffing levels.
0:27:47 > 0:27:50It's also providing new patient safety guidance this year,
0:27:50 > 0:27:55which will stress that owners must provide enough qualified staff.
0:27:57 > 0:28:00Our pharmacies are busy places, but they are safe places.
0:28:00 > 0:28:04We have an industry-leading patient safety record, we continue to invest,
0:28:04 > 0:28:08we continue to improve both our processes, our systems, our operations,
0:28:08 > 0:28:10to get even safer into the future.
0:28:13 > 0:28:18We do not want this to happen again, to someone else's mother,
0:28:18 > 0:28:19grandmother or sister.
0:28:20 > 0:28:24As long as the public, the patients, who are ultimately the ones at risk,
0:28:24 > 0:28:27and ultimately the ones that we're meant to be serving,
0:28:27 > 0:28:30as long as they don't know, then nothing will ever change.
0:28:30 > 0:28:35I'd like to think that this could be a catalyst to force an industry change.