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Dad’s death from potent skin drug ‘entirely preventable’

“Arrogant at best and stupid at worst.”

That’s how an expert has described the actions of a Melbourne GP who ignored a pharmacist’s warning that he’d prescribed a potentially lethal dose of medication.

Father-of-four Ian John Gilbert died from complications from methotrexate toxicity in 2015 after being dispensed the hardcore chemotherapy drug to treat a case of psoriasis, a common skin problem.

On Thursday Coroner Rosemary Carlin found that the 77-year-old’s death was “needless and entirely preventable”.

The case has cast a spotlight on a perceived power imbalance between pharmacists and GPs. Dispensing pharmacist Jennifer Barca said she knew when she handed over the medication that it could be deadly – as it was usually taken weekly, not daily.

But when she called Croydon GP Stephen Lim, he insisted the dosage he had given Mr Gilbert was correct, so she dispensed it anyway, the court heard.

Ms Barca was so concerned for Mr Gilbert’s safety she changed the instructions on the medication label, before changing it back.

The coroner questioned why Ms Barca, a veteran pharmacist of 35 years experience, did not refuse to dispense the drug.

“It appears that Dr Lim did not afford Ms Barca the respect she deserved,” Ms Carlin said.

“In dispensing the methotrexate despite her concerns, it appears that Ms Barca afforded Dr Lim too much respect, or at least lost sight of her role as an independent safeguard against inappropriate prescribing.”

An expert appearing for Mr Gilbert’s family, Dr Peter Hay, said it was significant that a pharmacist would question a patient’s drug dosage.

“To dismiss it out of hand without doing anything further is arrogant at best and stupid at worst,” said Dr Hay, a GP.

Dr Lim is still registered as a medical practitioner, but has been ordered to undergo an eight-hour education program and undertake an audit of practice.

Methotrexate has been linked to at least 61 deaths in Australia in the past decade and comes with numerous serious warnings, including that it should not be given to patients who, like Mr Gilbert, experienced kidney damage.

The coroner found Mr Gilbert should have never been prescribed methotrexate by his GP (rather he should have been referred to a dermatologist) and should have been given blood tests to check its safety.

Ms Carlin said she was compelled to make an adverse finding against both the GP and pharmacist.

“Mr Gilbert died because a dangerous drug was inappropriately prescribed and then dispensed,” she said.

“The fact the drug was intended to treat a non-life threatening condition makes his death all the more tragic and the decision to prescribe and dispense all the more inexplicable.”

Mr Gilbert was a former real estate agent and keen North Melbourne supporter who was especially close to his twin daughters, Amanda and Kristy Gilbert.

“Dad was funny and intelligent. If he was in the court today he would have had everyone laughing and everyone feeling really good and positive,” Kristy said.

Amanda said she didn’t want another family to go through the same thing.

“If this whole situation could be prevented for someone else, I think it’s a step in the right direction,” she said.

Mr Gilbert died in hospital on February 13 in 2015, about two weeks after he received the methotrexate prescription.

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