Recurring concern

Failure to reliably reconcile prescribed and dispensed medication

First to latest report 27 Jan 2014 — 27 Nov 2023

Reports that mention this concern
3
Times this concern has been raised
3
Stated actions linked to this concern
2

What this concern includes

Includes dedicated controls that compare, reconcile or cross-check medication dispensed against the relevant prescription or prescribing and dispensing history, including end-of-day pharmacist or third-party checks and cross-provider tracking needed to identify discrepancies.

What is not included
  • Excludes clinically inappropriate prescribing where no failure to reconcile prescribing and dispensing information is identified.
  • Excludes medication administration, monitoring, supply or adherence failures after prescribing and dispensing records have been reliably reconciled.
  • Excludes duplicate or discontinued-prescription prevention where the issue is prescription status rather than reconciliation of what was prescribed with what was dispensed.
  • Excludes generic record-keeping or pharmacy-governance deficiencies that do not directly impair prescribed-versus-dispensed medication reconciliation.

Reports and published responses 3 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Inner North London

    AI-generated summary

    Mohammed Zeeshan Akram (Zee) · 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

    Mohammed Zeeshan Akram, known as Zee, had a history of suicidal ideation and a psychotic disorder. He died at Whittington Hospital on 21 March 2023 after being found unresponsive at his flat. The principal concern was that GPs were not routinely informed when patients stopped taking prescribed medication, including where suicidal ideation or a risk of stockpiling might be present.

    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 routine cross-referencing between prescribed and collected medication

    Wider context from the report

    “I heard evidence that there was no routine mechanism to cross reference what people are prescribed and what medication they are actually collecting, and no automatic notification to GPs who are responsible for the medication prescribing. Zee informed BEH that he had not taken his olanzapine and fluoxetine for two weeks. His GP, who was prescribing that medication, was not informed. I am concerned that GPs are not updated, particularly where patients have expressed suicidal ideation, and may not be aware that people are not taking medication and/or that there may be a risk of stockpiling. ”

    Source location

    Mohammed Zeeshan Akram (Zee) · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Leicester City and South Leicestershire

    AI-generated summary

    Jamie Francis O'Connor · 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

    Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.

    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 central tracking of prescribed and dispensed drugs

    Wider context from the report

    “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

    Source location

    Jamie Francis O'Connor · 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

    Work with healthcare regulators on digital healthcare provision.

    Verbatim wording from the response

    “The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 4 November 2021

    Open published response

    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 the UK legislative position on digital healthcare and identify regulatory gaps.

    Verbatim wording from the response

    “The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 4 November 2021

    Open published response

    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

    A central system or database tracking prescribed and dispensed medicines, and the responsible individuals, is outside the remit.

    Verbatim wording from the response

    “We acknowledge your concern that there is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom. Although this specific aspect is outside of our remit, we do produce guidance, which is designed to support pharmacy owners and pharmacy professionals to meet our standards.”

    Source location

    2021-0363-Response-from-GPC_Published
    Page 2 · response
    Published 4 November 2021

    Open published response

    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

    Systems for accessing and sharing prescribing and dispensing information are outside the respondent’s remit.

    Verbatim wording from the response

    “Systems for accessing and sharing information about the prescribing and dispensing of medicines are outside the GMC’s remit. However, we strongly agree that effective systems are vital to ensuring safe and effective care.”

    Source location

    2021-0363-Response-from-GMC_Published
    Page 2 · response
    Published 4 November 2021

    Open published response

  3. York City

    AI-generated summary

    Judith Lesley Marshall · 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

    Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.

    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 end-of-day reconciliation of prescription-only drugs dispensed against prescriptions

    Wider context from the report

    “(5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances. ”

    Source location

    Judith Lesley Marshall · Prevention of Future Deaths report
    Page 2 · 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

    NHS England is responsible for commissioning pharmaceutical services and has addressed the concerns in its detailed response.

    Verbatim wording from the response

    “As Secretary of State for Health, I am responsible for setting national priorities, monitoring the whole system’s performance and supporting the integrity of the system to protect the best interests of patients, the public and the taxpayer. Since 1 April 2013, most day to day decisions are taken by NHS England. NHS England is responsible for commissioning primary care services, including pharmaceutical services.”

    Source location

    2014-0039-Response-by-Department-of-Health
    Page 2 · response
    Published 27 January 2014

    Open published response

    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

    Mandatory end-of-day prescription reconciliation is not introduced because evidence that it reduces dispensing errors is required.

    Verbatim wording from the response

    “5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.”

    Source location

    2014-0039-Response-by-NHS-England
    Page 3 · response
    Published 27 January 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026