RAF veteran died after pharmacy gave him wrong prescription

He received many different medications for complaints including heart problems and Type 2 diabetes.

Suffolk Coroner Dr Peter Dean, recording a narrative conclusion, said that Mr Lamond died from the combined effects of his serious pre-existing medical conditions and the consequences of "a very significant accidental dispensing error which resulted in him receiving another patient's medication".

He noted that this deprived Mr Lamond of his own medication for several days, and the other patient's medication was likely to have had harmful side-effects too.

Dispenser Susan Hazelwood said she had made the dispensing error on a day when the pharmacy was "very busy", and responsible pharmacist Mihaela Seceleanu did not notice this when completing checks.

Ms Hazelwood told Thursday's hearing at Suffolk Coroner's Court in Ipswich that weekly pill boxes were made up once every four weeks, stored on shelves and delivered weekly from the pharmacy in Orwell Road, Felixstowe.

She said Mr Lamond's prescription changed and he required extra pills.

She slit open a completed box, which she believed was for Mr Lamond, she added the pills and re-sealed the box with sticky tape, against standard procedures.

But she had accidentally picked up a completed box for another patient with a similar surname, Antony Lampard, which was two shelves above the boxes for Mr Lamond.

"We were very busy," she said. "We were doing a nursing home at the time and other boxes."

Ms Seceleanu, who qualified in Romania and moved to the UK in 2009, accepted she checked the pills that were added to Mr Lamond's pill box but said she may not have checked the rest of the details.

"I will forever regret this mistake," she said, in a written statement.

The Crown Prosecution Service (CPS) said there was insufficient evidence to charge anybody with gross negligence manslaughter.

Following a right to review appeal by the family of Mr Lamond, Ms Seceleanu was cautioned under the Medicines Act 1968.

This was for having supplied a product that was not of the nature demanded by the purchaser.

She said she may not have opened the box to see seven labels with Mr Lampard's name on it inside the pack.

Boots now requires pill boxes to have the name and address of a patient printed on the outside, Ms Seceleanu said.

Due to the prescription error, Mr Lamond was wrongly dispensed the anti-diabetic drug Gliclazide, which is used to lower blood sugar levels, and he did not receive his usual prescription of Bisoprolol, a beta-blocker used to treat high blood pressure.

Clinical pharmacologist Robin Ferner said this placed "frail" Mr Lamond at greater risk of suffering a heart attack.

The inquest heard it was "very likely" that this had "hastened his death".

Mr Lamond, of Stuart Close, Felixstowe, died on May 12 2012, two days after the pills were delivered to him.

The widower, who was born in Dundee, had served in the RAF as a bomb aimer and navigator, and lived alone at the time of his death.

Dr Jose Moss, deputy superintendent pharmacist for Boots UK, said an investigation found that shortfalls had resulted from human error, and that standard operating procedures were in place but had not been followed.

She told the family of Mr Lamond: "I would like to express on a personal level and on behalf of Boots UK my sincere apologies."

A Boots UK spokesman said: "We're so sorry for this tragic error.

"Our pharmacy has been providing care to the community in Felixstowe for many years, with patient care and safety at the heart of what we do.

"We'd like to extend our sympathies to Mr Lamond's family, and reassure our customers and patients that since this incident in 2012 we've shared the learnings from this incident to help prevent this happening in the future."