Norton man, Richard Anthony Lee, is believed to have taken double the amount of medication he should have when he was found on his bedroom floor on December 15, 2016.
Mr Lee was taken to Doncaster Royal Infirmary, where he died holding his daughter Gail Pickles' hand around five hours after first being admitted.
Deputy Superintendent Pharmacist for Boots UK, Dr Josephine Moss told Doncaster Coroners’ Court on Wednesday that she accepted the mix-up ‘ought not to have happened’.
Dr Moss added that the mistake was down to the error of an individual, and said she did not believe it had been caused by a failure in the operating processes of Boots UK.
Doncaster Coroners’ Court heard how after his prescription was sent to three different branches of Boots Pharmacy, Mr Lee was inadvertently given two lots of his prescription, one from the company’s pharmacy in the Frenchgate shopping centre and another from the branch attached to Askern Medical Practice, where Mr Lee was a patient.
Mr Lee’s prescription was initially sent to a Boots pharmacy branch in Church Street, Askern, in November 2016 but the pharmacy was unable to process the prescription causing it to be passed to the Frenchgate, before being sent to the branch attached to Askern Medical Practice.
When asked whether her father would have queried the delivery of two separate batches of the prescription drugs, Mrs Pickles said earlier this week that he would have thought he was 'expected' to take them, and would not want to 'cause a fuss'.
The court heard how details of a patient’s prescription, including details of a transfer from one pharmacy to another, should be recorded by staff in a ‘communication book’ that will subsequently be passed between branches as appropriate.
There was no entry concerning the prescription being moved from the Church Street branch to the Frenchgate one, but Dr Moss told the court she did not know whether this meant ‘something was said verbally’ instead.
Coroner, Louise Slater, told Dr Moss that during the course of the inquest several questions had been asked about how staff recorded things, such as the actioning of a task, and described the evidence around the company’s communication processes as being ‘very unclear’.
Dr Moss told the court that her expectation would be for staff to use the communication book as an opportunity to add any information about patients, including details of a transfer between pharmacies, and said this had been ‘clarified’ and communicated to staff in the wake of Mr Lee’s death.
She continued by saying that an appendix intended to be used to specifically record details of a pharmacy transfer had also been added to the communication book.
Dr Moss told the court that the situation concerning Mr Lee’s prescription was ‘unprecedented,’ referring to the family’s ‘numerous requests’ to change pharmacies in a short space of time, at the same time as the pharmacies were facing an increased demand on the service in the run-up to Christmas which she said may also have meant staff would not consider it unusual for patients to be requesting additional amounts of their normal prescription for the holiday period.
The court was told how the prescriptions given to Mr Lee included the antidepressant dosulepin and a range of drugs to reduce blood pressure - through Medisure packs, which lasted four weeks at a time.
Toxicologist Dr Stephen Morley, who gave evidence earlier this week, returned to the court to answer questions concerning the possible combined effect of taking double doses of seven different medications.
Dr Morley told the court he did not think ‘any GP would have increased the doses of seven medications in one go,’ but added he could not say whether he believed the additional doses were likely to have contributed to Mr Lee’s death, based on the evidence he had seen.
Ms Slater adjourned Mr Lee’s inquest until Thursday, July 5, when she is expected to deliver a conclusion.