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