Recurring concern

Unreliable pharmacy clinical guidance and procedures

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First reported 11 May 2016•Latest report 17 May 2024

Definition

What this concern includes

Includes deficiencies in pharmacy-specific clinical guidance, policies or procedures where they are contradictory, absent, unclear or insufficiently implemented and the deficiency can affect safe prescribing, dispensing or pharmacy practice, including the anchor's contradictory corporate pharmacy guideline documentation and the separate deficiency in local practitioner guidance for implementing NICE NSAID prescribing documentation.

Not included

Excludes clinical guidance deficiencies unrelated to pharmacy practice unless the report explicitly identifies a pharmacy-specific guidance or procedure failure.
Excludes generic failures to follow clinical guidance where no deficiency in pharmacy guidance, policy or procedure is identified.
Excludes pharmacy staffing, resourcing, dispensing, controlled-drug regulation or operational-process failures unless the report directly identifies pharmacy guidance or procedures as the unsafe condition.
Excludes guidance omissions concerning unrelated clinical systems, beneficiaries or hazards where no pharmacy-specific guidance boundary is supported.

Reports: 4
Individual concerns: 4
Date range: 2016–2024
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.

Circle Health Group Limited1

Department of Health and Social Care1

General Pharmaceutical Council1

NHS Lincolnshire Integrated Care Board1

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.

17 May2024
Greater Lincolnshire
Concerns raised1
1. Lack of local practitioner guidance on practical implementation of NICE NSAID prescribing issues documentation
This report raised 2 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
  Add a reminder about co-prescribing PPIs with NSAIDs to the Lincolnshire Formulary.
  Stated by NHS Lincolnshire Integrated Care BoardStated planned
AI-generated summary

Jonathan Paul SZCZEPANSKI · 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

Jonathan Paul Szczepanski had been prescribed Naproxen regularly for several years without a corresponding proton pump inhibitor or medication reviews addressing the risks of long-term NSAID use. He was admitted with symptoms indicative of a gastrointestinal bleed, did not respond to treatment, and subsequently died. The inquest concluded that he died from a duodenal ulcer, to which Naproxen treatment without a corresponding PPI made a contribution. Concerns included a lack of local prescribing guidance, prescribing software without specific NSAID warning flags, and discharge documentation without relevant warnings.

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
Lack of local practitioner guidance on practical implementation of NICE NSAID prescribing issues documentation
Wider context from the report
“(1) There is a lack of local practitioner guidance on the practical implementation of the NICE NSAIDs - prescribing issues documentation. ”
Source location
Jonathan Paul SZCZEPANSKI · 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
Add a reminder about co-prescribing PPIs with NSAIDs to the Lincolnshire Formulary.

Verbatim wording from the response
“ICB response It is long-standing accepted practice, as per NICE guidelines, that PPIs should be considered as a co-prescription with NSAIDs for at risk patients.”

Source location
2024-0271 Response from Lincolnshire Integrated Care Board
Page 1 · response
Published 20 May 2024
Open published response
18 Nov2019
Suffolk
Concerns raised1
1. Lack of mandatory online-prescription guidance and effective sanctions for non-adherence
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

Deborah Michelle HEADSPEATH · 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

Debbie Headspeath died suddenly at home on 28 July 2017 from aspiration pneumonitis caused by pancreatitis, which was linked in the report to long-term codeine use. The principal concerns were the lack of a central database for prescription-only medicines, uncoordinated access to codeine from multiple online suppliers, and the ability of some suppliers to operate outside the CQC regulatory regime.

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
Lack of mandatory online-prescription guidance and effective sanctions for non-adherence
Wider context from the report
“3. New guidance from the General Pharmaceutical Council was issued in April 2019 and this includes specific advice regarding on-line prescriptions. This is clearly welcome, however some witnesses highlighted that the guidance is advisory and not mandatory. As such there was some uncertainty as to what sanctions would be available against any supplying pharmacist who chose not to adhere to the new guidance? ”
Source location
Deborah Michelle HEADSPEATH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Oct2017
Manchester North
Concerns raised1
1. Lack of specific regulatory guidance on pharmacy red-flag systems for patients with potentially confusing identities or addresses
This report raised 1 other concern. 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
  Produce guidance for pharmacy owners and superintendent pharmacists on safely providing pharmacy services at a distance, including medicine delivery and staff training.
  Stated by General Pharmaceutical CouncilStated completed
AI-generated summary

Ms Christina Ann Fletcher · 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

Ms Christina Ann Fletcher was found dead at home after Zomorph, an opiate and controlled drug, was mistakenly delivered to her on 4 August 2016 and the error went undetected. Post-mortem examination found markedly elevated free morphine, which was attributed directly to the cause of death. Concerns were raised about the absence of specific regulatory guidance on pharmacy red-flag systems for similar names and addresses, and on the chain of custody for controlled drugs.

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
Lack of specific regulatory guidance on pharmacy red-flag systems for patients with potentially confusing identities or addresses
Wider context from the report
“1. There is no specific guidance, policy or protocol from the GPhC on the requirement for a ‘red flag’ system within pharmacies in relation to patients with identical names, similar addresses, living in close proximity etc. as demonstrated by the very tragic circumstances of this case. Whilst the Pharmacy in question did have internal processes in place at the time, concern remains that other Pharmacies throughout England and Wales might not, in the absence of specific guidance from their Regulator. ”
Source location
Ms Christina Ann Fletcher · 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
Produce guidance for pharmacy owners and superintendent pharmacists on safely providing pharmacy services at a distance, including medicine delivery and staff training.

Verbatim wording from the response
“We publish a range of guidance, which is focussed on helping pharmacy professionals, pharmacy owners and superintendent pharmacists meet our regulatory standards. We have produced guidance for pharmacy owners and superintendent pharmacists who provide services at a distance:”

Source location
Christina-Fletcher_Redacted
Page 3 · response
Published 27 November 2017
Open published response
11 May2016
Preston and West Lancashire
Concerns raised1
1. Corporate pharmacy guideline documentation contradicting NICE guidance
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

Sally Ann Tooze Froggatt · 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

Sally Ann Tooze Froggatt died on 6 April 2015 at Royal Lancaster Infirmary following multiple missed opportunities to treat her high risk of venous thromboembolism. Concerns included failures in the Duty of Candour, inadequate staff training, potentially contradictory pharmacy guidance, and failure to raise known risk factors with consultants.

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
Corporate pharmacy guideline documentation contradicting NICE guidance
Wider context from the report
“3. corporate pharmacy guideline documentation that appears to contradict the NICE guidance referred to in other corporate literature ”
Source location
Sally Ann Tooze Froggatt · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of local practitioner guidance on practical implementation of NICE NSAID prescribing issues documentation

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

Lack of mandatory online-prescription guidance and effective sanctions for non-adherence

Concerns raised1

Lack of specific regulatory guidance on pharmacy red-flag systems for patients with potentially confusing identities or addresses

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

Corporate pharmacy guideline documentation contradicting NICE guidance

Actions described in response 1

Actions described in response 1