The death of a Creston woman from a fatal interaction between two prescription drugs has led to a call from the B.C. Health Professions Review Board for mandatory reporting of adverse drug reactions.

Helena Lambert's 2012 death has already led to regulatory sanctions against a doctor and three pharmacists who were ultimately deemed to have failed the 76-year-old in issuing the medication and overlooking warnings about the risk.

In a decision prompted by a complaint from Lambert's son, the review board says the province should act to prevent future tragedies.

"The unique circumstances of this case warrant my respectfully offering some observations from the tragic circumstances of this case," writes board member Marilyn Clark.

"One is that all health practitioners in British Columbia be required, as they are in the case of gunshot wounds, to report medication incidents with adverse outcomes in order to reduce the number of occurrences in future cases. It should not be left to grieving families to report these incidents."

'Still looking for accountability'

The review board has no authority to force a change in legislation, but Lambert's son says he hopes the province is listening. 

Three years after a nightmare that began with a blister on his mother's foot, Ernie Lambert says the pain of her ordeal is still emotionally raw for him. He wants to ensure it doesn't happen to anyone else.

"No matter what I do, it's not going to bring my mum back," he said. "But if we can get something out of this — and their recommendation is a pretty strong something — I would really like to see that. The other thing is, I'm still looking for accountability."

Ernie Lambert

Ernie Lambert feels the system failed his mother, Helena, and he wants to warn other patients to beware. (CBC)

Lambert spoke to CBC's Go Public in 2014 about the situation. 

Helena Lambert was an active, independent woman who had been prescribed a total of 12 medications for conditions including colitis, chronic kidney disease and chronic obstructive lung disease.

In June 2012, she was prescribed allopurinal after being diagnosed with gout. Several weeks later, after developing a blister, Lambert was transported to hospital.

A physician concluded that the interaction between the Allopurinal and another drug, mercaptopurine, was causing her immune system to shut down. Lambert died on September 3.

According to the review board decision, a physician at the hospital said: "this should never have occurred, it was 100 per cent preventable."

Suspensions and education

In the wake of his mother's death, Ernie Lambert complained to both the B.C. College of Physicians and Surgeons and the College of Pharmacists of B.C.

Lambert's doctor was required to take a course for his mistake; he told his regulator he relies on pharmacists to check on adverse drug interactions.

Two of the pharmacists received 30-day suspensions and their manager was required to implement pharmacy policy and training on assessing drug-related problems.

But Lambert appealed both decisions to the review board. He said the board has yet to make a decision on the ruling by the College of Physicians and Surgeons.

According to the review board, one of the pharmacists has moved to another jurisdiction and another left the practice and is dealing with severe depression as a result of the incident. 

Clark upheld the sanctions against the pharmacists, finding the college's investigation adequate and the decision reasonable.

But she acknowledged Lambert's concerns with the call for mandatory reporting.

At present Health Canada's MedEffect database collects reports of adverse reactions to medication in Canada. According to the department, manufacturers and hospitals are obliged to report them, whereas consumers and health professionals are "invited" to report.

"A sector-wide reporting requirement would go a long way toward ensuring that the maximum future learning and prevention benefits — perhaps including the updating of drug interaction databases — are extracted from unfortunate incidents," wrote Clark.

'It needs to apply across the board'

University of Victoria drug policy researcher Alan Cassels says the province should take Clark's suggestion seriously.

He says authorities should treat adverse drug interactions like any other threat to public safety.

"They convene all kinds of investigations to determine what went wrong, and that information is used to prevent it happening in the future," he said.

"With the drug world, there's no teams of investigators jumping up to investigate drug errors because most of the time they're never really reported."

Clark suggested that at the very least, B.C.'s college of pharmacists should use its authority to force its registrants to report adverse reactions.

"It needs to apply across the board," Lambert said. "Forcing the reporting of these incidents would certainly increase the accountability significantly."

Read the Health Professions Review Board decision: