Licences of 2 Thunder Bay pharmacists suspended after misconduct

Two Thunder Bay pharmacists have had their professional licences suspended for several months after their provincial regulator found instances of misconduct, including breaking therapy guidelines for treating opioid use disorder. 

Jaspreet Sahota and Chi (Hao) Luu both admitted to committing misconduct while working at Fort William Medical Pharmacy during separate hearings before the Ontario College of Pharmacists on April 22 and May 5. 

The college investigated after receiving reports of numerous issues at the Victoria Avenue pharmacy in February and March 2023, including dispensing medications without a prescription, not checking dispensed medications and billing patients for medications that were never dispensed, according to an agreed statement of facts signed by Sahota.

Unregulated staff were dispensing methadone, the statement also said.

Sahota, who was the owner and designated manager of the pharmacy, received a 10-month licence suspension, a five-year ban from managing pharmacies and was required to pay $15,000 in costs to the college.

• If you have any more information related this story, contact Michelle Allan at michelle.allan@cbc.ca or (343) 552-1972 

The college imposed a seven-month licence suspension on staff pharmacist Luu. He was also prohibited from acting as a pharmacy manager for one year and required to pay costs of $10,000. 

CBC reached out to Sahota by email and phone but did not receive a response by publication time. Luu declined to comment when contacted through his lawyer. 

CBC also contacted McKesson Canada, a corporation that provides support to independently owned pharmacies like Fort William Medical Pharmacy under the banners Guardian, I.D.A. and Remedy'sRx. 

"Guardian pharmacies are owned and operated by independent pharmacists who manage their own operations and are governed by the rules and regulations of their provincial regulatory body. The Fort William location is currently under receivership and is operating under new management," a McKesson Canada spokesperson said in an email to CBC. 

Lawyer Jordan Stone, who represented the college, said at Sahota's hearing that the clear pattern of multiple types of misconduct repeatedly occurring at Fort William Medical Pharmacy was an aggravating factor. 

"There's failures in a wide range of areas here. This is not just one element of Mr. Sahota's practice or the pharmacy's operation that fell below standards. We had issues across the board." 

Patient accidentally dispensed 10-fold overdose 

An agreed statement of facts cites a March 2023 medication error where a patient was accidentally given a methadone dose 10 times stronger than their regular prescribed dose.

Methadone is a synthetic opioid that is frequently used to treat opioid use disorder. It's a type of opioid agonist treatment that reduces the risk of overdose in drug users by using medications to prevent withdrawal symptoms.

The patient was dispensed 250 milligrams of methadone instead of 25 milligrams, the statement said. 

"This prescription was signed by Mr. Luu but was measured and dispensed by a pharmacy assistant without Mr. Luu checking the prescription. A medication incident form was not completed for this error."

The hearing documents do not indicate what happened to the patient. 

Personal injury lawyer Brian Goldfinger said he has seen an increase in clients seeking representation after accidental methadone overdoses as a result of prescribing errors in recent years.

Methadone overdose can be fatal, said Goldfinger, who owns Toronto-based firm Goldfinger Law. He is not connected to the Fort William Pharmacy incident, but spoke broadly about his experiences representing clients who have been afffected by dispensing errors. 

Many of his clients have been hospitalized for extended periods with symptoms such as muscle damage, inability to walk, severe pain and headaches, he said. Reintroducing large amounts of opioids to someone trying to wean themselves off an addictive substance can be destabilizing, Goldfinger said.

"What happens oftentimes is it causes them to relapse. So all the great recovery that they've made has all been kind of flushed down the toilet as a result of the dispensing error. And then, they have problems kind of weaning off the methadone and getting back to normal … and this completely sets them back." 

Staff pharmacist overwhelmed, panel hears

Fort William Medical Pharmacy had an influx of hundreds of opioid agonist therapy patients from an adjacent addiction treatment centre after a neighbouring pharmacy closed in January 2023, according to reports by the college that were included in the Sahota hearing documents. 

"The pharmacy's volume has dramatically increased with a limited increase in staffing," said a July 2023 pharmacy assessment report attached to the agreed statement of facts Sahota signed.

Sahota, the designated manager, did not take an active role in the pharmacy's day-to-day management, said the agreed statement of facts. This left Luu as the sole pharmacist working in the pharmacy. 

Luu's lawyer, Sari Feferman, said at his discipline hearing that Luu was overwhelmed by the rapid increase in patients and did not have adequate equipment, personnel or resources. 

"If [Luu] were to testify, he would state that at all material times, he felt he had an obligation to assist in serving the [the treatment centre's] patients, but he had no ulterior motive and did not benefit personally or financially from doing so," said the agreed statement of facts signed by Luu. 

Patients billed for meds never received: report

In addition to the medication error, the hearing documents described concerns with prescription documentation, billing practices and management of controlled substances.

Luu falsified records to make it appear as though he had clinically verified or dispensed prescriptions, said the summary of his hearing posted on the college website. 

"The pharmacy accepted and dispensed prescriptions that were not signed by a prescriber. These prescriptions were reprinted and stated words to the effect of 'not an official prescription,'" the agreed statement of facts from Sahota's hearing said. 

Luu admitted to dispensing drugs without a proper prescription, in contravention of Ontario's Drug and Pharmacies Regulation Act. 

Sahota and Luu both admitted to billing patients for prescriptions they never received. 

The pharmacy was also left open and dispensed drugs without a pharmacist present, according to the agreed statement of facts signed by Sahota. 

Sahota also admitted he broke federal Narcotic Control Regulations by failing to protect drugs at the store from loss or theft. 

Counts of controlled substances often found discrepancies, according to pharmacy assessment reports.

In some cases, the pharmacy was short tablets of multiple drugs. At other times, it had more tablets of controlled substances than indicated by purchase and dispensing records.

Controlled substances taken during robbery

Fort William Medical Pharmacy was robbed in March 2023 and May 2023, but didn't properly count or reconcile controlled substances, said the agreed statement of facts. 

It reported losses of about 2,000 of tablets of suboxone, roughly 1,500 tablets of the sedative clonazepam and nearly three litres of a liquid methadone formulation.

Both robberies were reported to police and arrests were made in each case, the Thunder Bay Police Service confirmed to CBC in an email. The two men arrested were not Sahota and Luu.

"It was noted that there were many manual adjustments made [to the controlled substances inventory] before and after the robbery where no supporting documentation was available to explain the reason for the adjustment," read the July 2023 pharmacy assessment report attached to the agreed statement of facts Sahota signed. 

Luu's misconduct eroded public trust in pharmacists, college panel head Megan Peck told Luu in an oral reprimand at his discipline hearing. 

"At a time when the opioid crisis is front and centre in the minds of the public, this panel finds your actions and breaches particularly concerning as you have put the lives of an already vulnerable population in further danger," said Peck. 

Sahota, Luu and a third pharmacist linked to Fort William Medical Pharmacy all have additional pending disciplinary hearings that have yet to be scheduled. 

The latest allegations, referred to the college on March 24, accuse each of the three pharmacists of falsifying records and billing for medication reviews that were never conducted or done improperly, according to the college. 

Sahota also faces allegations of taking or misappropriating drugs from the Fort William Medical Pharmacy.