A concerned daughter wants to see pharmacy packing policies change after a Webster-pak mishap eroded her mother’s health, leaving her in need of constant care.
Lisa Carratelli said she has watched her 87-year-old mother Maria’s health deteriorate who is now unable to walk or eat on her own after a pharmacy mistake allegedly caused her to overdose on her own medication, claiming “the pharmacist nearly killed her”.
Having been prescribed methotrexate by her doctor, a chemotherapy drug used to treat some cancer, autoimmune diseases and rheumatoid arthritis, Maria began feeling unwell and complained of a consistent sore throat.
Maria was eventually sent to Maroondah Hospital in Victoria where doctors inspected her Webster-pak and were alarmed when they found the 87-year-old was taking seven times the prescribed amount.
Maria was then sent to Box Hill Hospital and her discharge documents allegedly stated Maria was suffering from “methotrexate toxicity resulting in Mucositis with Pancytopenia” the terms used to define low levels of red blood cells.
“She was supposed to take two [tablets] once a week but the pharmacy had packed the Webster packs with two tablets daily,” Lisa told Yahoo News Australia.
Aside from her burns, Maria lost her hair — a common side effect of chemotherapy, and is now living in a nursing home to receive consistent care, funded by Lisa’s dad’s pension.
Lisa has alleged the pharmacist, who is a friend of the family apologised after learning what had happened, but claimed it wasn’t he who made the medication pack.
Lisa has also reached out to a number of solicitors for advice and the Pharmacy Board of Australia to report what she claims to be pharmaceutical malpractice but all have allegedly said there’s nothing that can be done for her mother due to her age.
Lisa is now calling for it to be mandatory across the board for all prescriptions to be checked by two pharmacists before being handed out – a double-checking process that is usually determined by the individual pharmacist.
She said, “I want to help people to understand why they should always check the medication and not just trust the pharmacist.”
A Spokesperson for the Australian Health Practitioner Regulation Agency is said to have told Yahoo News Australia:
“When dispensing medicines, pharmacists should be guided by professional practice standards, the Pharmacy Board of Australia’s code of conduct and guidelines for pharmacists including: guidelines for dispensing of medicines [and] guidelines on dose administration aids and staged supply of dispensed medicines.”
Blister packs can be convenient but as a nurse I prefer the method of checking doctor’s order and having the bottle of medication locked in the clients’ draw or medication trolley. Therefore every time administration is conducted you are doing the 3 checks.
Unfortunately that means we need to find more nurses nationally to execute this. I am a strong advocate for more nurses at the bedside or community level where we also educate the client and importantly pick-up on any changes in the client and report immediately to the doctor.
Best practice seems to be slowly eroded because of the cost.
I have had my sister’s medication mispacked 3 times by a chemist we started going to in October, 2025.
I told the chemist. She didn’t seem to care. She did not offer me a replacement webster pack. I noticed the same initials on the “packed by” and “checked by” on the webster pack.
My sister has dementia and I’ve had to change chemists twice before due to this problem of mis packing.
I’m concerned I will end up accused of giving my sister the wrong, or too much medication.
I have become extra vigilant. But I’m not a chemist and do my best.
This incorrect packing is affecting vulnerable and elderly patients and is impacting carers like me. Stronger rules need to be in place. Maybe less mistakes would occur if a machine was used?