 The case confirmed that a serious error in giving a vulnerable customer a potent drug that does not match in any way the prescription, where such action is not the primary causation of any death or suffering, can result in a prosecution of the responsible pharmacist, with up to 2 years of maximum imprisonment, depending on the circumstances.Later guidance and regulation has protected responsible pharmacists able to prove they have adequate, strict safeguards in place and also laid out principles to help to foster those safeguards.A cancer-suffering patient with poor respiratory health died three days after Pharmacist Elizabeth Lee dispensed or co-dispensed the wrong drug; a full investigation of facts followed and Lee reported the error which was before trial found not to have been the primary cause of death.