Recurring concern

Unreliable communication between pharmacies and clinical teams

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First reported 13 Mar 2014•Latest report 18 Aug 2023

Definition

What this concern includes

Includes failures in the bounded communication interface between pharmacies and clinical teams, including sending, receiving, acknowledging, clarifying and escalating pharmacy queries, prescription problems and medication-related information needed for safe care.

Not included

Excludes generic communication, documentation or escalation deficiencies where pharmacy and clinical-team communication is not the identified unsafe condition.
Excludes pharmacy dispensing, prescribing, medication administration or supply failures where the communication interface itself is not deficient.
Excludes communication between clinical teams or between pharmacies and patients where no pharmacy-to-clinical-team safety communication is involved.
Excludes failures occurring after relevant pharmacy information has been reliably communicated and the remaining issue is a clinical decision or treatment action.

Reports: 4
Individual concerns: 4
Date range: 2014–2023
Stated actions: 2

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Aneurin Bevan University LHB1

Cwm Taf Morgannwg University Local Health Board1

Droylsden Road Family Practice1

Greater Manchester Mental Health NHS Foundation Trust1

NHS England1

North Caerphilly Community Mental Health Team1

Recipient name withheld1

Senedd Cymru1

South Tyneside and Sunderland NHS Foundation Trust1

The Lawn Medical Practice1

Welsh Government1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

18 Aug2023
Inner South London
Concerns raised1
1. Failure of GP and pharmacist to communicate when prescription instructions are unclear or conflicting
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Discuss liquid morphine safety with London ICB medication-safety representatives and provide regional oversight of action-plan implementation, including communications to GPs and community pharmacists.
  Stated by NHS EnglandStated planned
AI-generated summary

Juanita Boate Nti · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Juanita Boate Nti had complex congenital diseases and was receiving palliative care at home. She received twenty times the intended morphine dose after the prescription and symptom control plan failed to clearly specify the volume, and the prescription contained two different concentrations. She suffered respiratory arrest and died following an accidental morphine overdose, with concerns also identified about the EMIS prescribing system not offering the relevant morphine strength.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of GP and pharmacist to communicate when prescription instructions are unclear or conflicting
Wider context from the report
“The hospital originally prescribed 120 micrograms of morphine sulphate 6 hourly and dispensed 100 micrograms per ml solution, but the strength and volume to be administered were not clearly recorded on the plan sent to the GP. The mother requested her GP by telephone to continue the prescription. The GP found only one strength of morphine on the EMIS prescription system, 10mg/5ml, confirmed to be the lowest strength available in the British National Formulary. He wrote this in the first line of the prescription and then confusingly further added “100 micrograms per ml solution, 120 micrograms 6hrly”. The pharmacist did not notice that the second line contained a different concentration and dispensed the higher dose without stipulating the volume to be administered. The baby received 3mg instead of the intended 150 micrograms. Whilst both GP and pharmacist made errors in clinical practice and did not contact each other, the error would not have occurred had another strength of morphine been a choice on EMIS. EMIS have been notified and placed the special prescription on its drug data base. The local commissioning group is conducting a project to identify other special prescriptions that are not on EMIS that may pose a similar risk to safety. ”
Source location
Juanita Boate Nti · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Discuss liquid morphine safety with London ICB medication-safety representatives and provide regional oversight of action-plan implementation, including communications to GPs and community pharmacists.

Verbatim wording from the response
“The London region Controlled Drugs Accountable Officer will also be discussing this issue with all London ICB medications safety representatives and ensure regional oversight of implementation of action plans which will include communications to GPs and community pharmacists.”

Source location
Response from NHS England
Page 2 · response
Published 6 September 2023
Open published response
15 Oct2021
Manchester City
Concerns raised1
1. Inadequate communication with and from the Pharmacy team
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  The GP practice is to provide the response concerning medication prescribing, correspondence handling, pharmacy communication and escalation processes.
  Stated by Greater Manchester Mental Health NHS Foundation TrustRedirects responsibility
AI-generated summary

Darren John Lawrence · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inadequate communication with and from the Pharmacy team
Wider context from the report
“f. The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate. As was communication with and from the Pharmacy team. Nor was there consideration of a system or process for contacting the secondary care provider GMMH in such circumstances when medication was not prescribed as requested and no contact could be made with the deceased. There was no escalation process/procedure. ”
Source location
Darren John Lawrence · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The GP practice is to provide the response concerning medication prescribing, correspondence handling, pharmacy communication and escalation processes.

Verbatim wording from the response
“GP to provide response”

Source location
2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Page 4 · response
Published 21 October 2021
Open published response
9 Jul2015
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
1. Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr. Alun Walters · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr. Alun Walters, who was prescribed Warfarin following receipt of a metallic heart valve, died after a gastro-intestinal haemorrhage in circumstances of suspected elevated Warfarin levels and failed INR monitoring. His prescriptions continued despite no INR tests after November 2013, and 51 prescriptions were provided without dosage assessment. Concerns included failures by the medical practice in monitoring, prescription systems and notifying the pharmacy that Warfarin had been withdrawn, while the pharmacy supplied Warfarin without a valid prescription.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
Wider context from the report
“The Lawn Medical Practice - (1) failed to use any computer software programmes to support its prescription decisions; (2) breached its contract with the Aneurin Bevan University Health Board in the development and maintenance of an anti-coagulation treatment register; (3) failed to put into place a system of notification to the GP and the Health Care Assistant of a patient’s failed attendance for INR testing; and (4) failed to advise the Rhymney Pharmacy Ltd. that Warfarin had been withdrawn due to a lack of INR safety testing. ”
Source location
Mr. Alun Walters · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Mar2014
Sunderland
Concerns raised1
1. Failure to communicate pharmacy queries effectively
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review pharmacy-team communication and escalation of medication omissions to identify workable solutions.
  Stated by South Tyneside and Sunderland NHS Foundation TrustStated in progress
AI-generated summary

Mrs Jean James · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs Jean James was admitted to the Acute Medical Unit on 24 December 2013, where prophylactic Dalteparin was intended but not prescribed. A pharmacy query was not effectively communicated, and the omission was not subject to effective review. Mrs James died on 8 January 2014; the post-mortem identified bilateral pulmonary thromboembolism due to deep venous thrombosis, and the inquest concluded: “Natural Causes Contributed to by Neglect”.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to communicate pharmacy queries effectively
Wider context from the report
“3) When the pharmacy raised a query, it was not communicated effectively. ”
Source location
Mrs Jean James · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review pharmacy-team communication and escalation of medication omissions to identify workable solutions.

Verbatim wording from the response
“3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions.”

Source location
2014-0112-Response-by-City-Hospitals-Sunderland
Page 2 · response
Published 13 March 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of GP and pharmacist to communicate when prescription instructions are unclear or conflicting

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Inadequate communication with and from the Pharmacy team

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing

Concerns raised1

Failure to communicate pharmacy queries effectively

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 1

Respondent positions 1

Actions described in response 1