Recurring concern

Unreliable packaging and identification of dispensed medication

First to latest report 29 Feb 2016 — 2 Jun 2024

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
11

What this concern includes

Includes failures in the dispensing-packaging process that affect the suitability, integrity, clear identification or patient-specific differentiation of dispensed medicines and compliance aids, including unsafe transfer from original unit-dose packaging and insufficient differentiation of medication packs for people living together.

What is not included
  • Excludes prescribing, dose selection and clinical medication-review failures where dispensing packaging or identification is not the deficient control.
  • Excludes medication administration failures after the dispensed medicine and its intended patient have been reliably identified.
  • Excludes generic medication shortages, supply delays, storage failures and disposal failures not involving packaging or identification of dispensed medicines.
  • Excludes general record-keeping or communication deficiencies unless they directly impair the packaging, identity or patient-specific differentiation of dispensed medication.

Reports and published responses 4 reports

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

  1. Berkshire

    AI-generated summary

    Sewa Kaur Chaddha · 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

    Sewa Kaur Chaddha was found collapsed at home after taking her husband’s medication instead of her own for several days, including diabetes medication. She died in hospital from hyponatraemia caused by treatment for hypoglycaemia resulting from the accidental ingestion of hypoglycaemic medication. Concerns included the identical appearance of the couple’s dosset boxes, small patient-name labels, and the absence or poor dissemination of guidance for pharmacists supplying medication to people with cognitive impairment.

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    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 adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address

    Wider context from the report

    “1) The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis. (2) Both patients were elderly and had cognitive impairment. (3) The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name. (4) Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days. (5) Evidence was given at the inquest that there was no guidance or policy in place for Pharmacists to follow when issuing medication to patients with cognitive impairments, or if there was, it was not well disseminated among the pharmacist population. (6) Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address. ”

    Source location

    Sewa Kaur Chaddha · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Consider adding wording recommending clear medicine labelling to distinguish household members, particularly those who are elderly or cognitively impaired.

    Verbatim wording from the response

    “13. The SPS will consider including additional wording to that in Annex 1, to recommend that medicines are clearly labelled for differentiation between household members, particularly for patients who are elderly and/or have cognitive impairment.”

    Source location

    Response from Specialist Pharmacy Service
    Page 3 · response
    Published 15 October 2024

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    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 existing guidance and consider refinements for supporting patients with cognitive impairments.

    Verbatim wording from the response

    “The NPA supports its Member pharmacies with advice, guidance and resources to help them to provide person-centred care in accordance with the pharmacy regulator’s, the General Pharmaceutical Council’s, standards. Our support includes guidance on equality, diversity and inclusion, monitored dosage systems (dosette boxes) and reasonable adjustments, including guidance on conducting patient assessments to help pharmacies determine how best to support patients with different needs including visual impairment, confusion and dementia, and signposting to information and support from the General Pharmaceutical Council.”

    Source location

    Response from National Pharmacy Association
    Page 1 · response
    Published 15 October 2024

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    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

    Raise the risk of confusing multi-compartment aids in one household with the Royal Pharmaceutical Society and request consideration of additional guidance or information.

    Verbatim wording from the response

    “Our action. We will bring this concern – the need for different MCAs in one household to be very clearly identified in such a way that those with cognitive impairment remain safe and take their medicines - to the RPS and the Community Pharmacy Patient Safety Group (CPPSG), and ask each to consider additional guidance and/or information to be made available to pharmacies and pharmacists. We will also make community pharmacy owners we represent aware of this concern or specific risk, initially ourselves and subsequently if the RPS or CPPSG issues any advice or reports. We will seek to take these actions in the autumn of this year.”

    Source location

    Response from Community Pharmacy England
    Page 2 · response
    Published 15 October 2024

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    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

    Raise the risk of confusing multi-compartment aids in one household with the Community Pharmacy Patient Safety Group and request consideration of additional guidance or information.

    Verbatim wording from the response

    “Our action. We will bring this concern – the need for different MCAs in one household to be very clearly identified in such a way that those with cognitive impairment remain safe and take their medicines - to the RPS and the Community Pharmacy Patient Safety Group (CPPSG), and ask each to consider additional guidance and/or information to be made available to pharmacies and pharmacists. We will also make community pharmacy owners we represent aware of this concern or specific risk, initially ourselves and subsequently if the RPS or CPPSG issues any advice or reports. We will seek to take these actions in the autumn of this year.”

    Source location

    Response from Community Pharmacy England
    Page 2 · response
    Published 15 October 2024

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    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

    Inform represented community pharmacy owners about the risk of confusing multi-compartment aids in one household.

    Verbatim wording from the response

    “Our action. We will bring this concern – the need for different MCAs in one household to be very clearly identified in such a way that those with cognitive impairment remain safe and take their medicines - to the RPS and the Community Pharmacy Patient Safety Group (CPPSG), and ask each to consider additional guidance and/or information to be made available to pharmacies and pharmacists. We will also make community pharmacy owners we represent aware of this concern or specific risk, initially ourselves and subsequently if the RPS or CPPSG issues any advice or reports. We will seek to take these actions in the autumn of this year.”

    Source location

    Response from Community Pharmacy England
    Page 2 · response
    Published 15 October 2024

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    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

    Double-check each tray with the patient after removing it from packaging.

    Verbatim wording from the response

    “Upon finding out we have amended our processes further to ensure that this does not happen again. We operate strict standard operating procedures which involve each tray being removed from packaging and double checked again with the patient.”

    Source location

    Response from Slough Pharmacy
    Page 1 · response
    Published 15 October 2024

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    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

    Provide differently branded trays with distinct packaging to households where multiple people use trays.

    Verbatim wording from the response

    “We have further added to our SOPs, and now provide a different brand of trays with totally different packaging to any households that involve more than one person with trays.”

    Source location

    Response from Slough Pharmacy
    Page 1 · response
    Published 15 October 2024

    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

    Community pharmacies are independent contractors under a national framework, limiting the ICB’s direct influence over their processes.

    Verbatim wording from the response

    “I am replying as the Chief Pharmacist for NHS Frimley, responsible for medicines optimisation and pharmacy across our system. While we recognise our duty to address the concerns raised, it is important to note that community pharmacies and other healthcare professionals operate as independent contractors under a national framework or contract, limiting our direct influence over their processes.”

    Source location

    Response from Berkshire Integrated Care Board
    Page 1 · response
    Published 15 October 2024

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    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

    Different dosette or label colours are not currently available because legal labelling requirements limit community pharmacy options.

    Verbatim wording from the response

    “Dosette boxes are not always suitable or the only solution for supporting a patient in taking their medication. Although various types of dosette boxes are available for purchase by the public, there are only a limited number used within community pharmacy due to the requirement that dosettes used must enable fulfilment of the legal labelling requirements. These are not currently available in different colours or label colours.”

    Source location

    Response from Berkshire Integrated Care Board
    Page 3 · response
    Published 15 October 2024

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    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

    Pharmacy dispensing concerns fall outside the medicines regulator’s remit, which covers medicines placed on the UK market.

    Verbatim wording from the response

    “We have reviewed the matters of concern and do not believe we are the right organisation to take these matters forward. We are the medicines regulator, and our approvals cover the placing of medicines onto the market, in their original packaging and are designed to ensure the safety, quality and efficacy of medicines on the UK market.”

    Source location

    Response from MHRA
    Page 1 · response
    Published 15 October 2024

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    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

    Concerns about pharmacists’ dispensing actions should be addressed to the General Pharmaceutical Council, the pharmacy and pharmacist regulator.

    Verbatim wording from the response

    “However, the matters of concern relate to actions taken by a pharmacist during the dispensing process, and we believe therefore they are better addressed to the regulatory body for pharmacies and pharmacists, the General Pharmaceutical Council. A link to their website and an email address for their enquiry team can be found below:”

    Source location

    Response from MHRA
    Page 1 · response
    Published 15 October 2024

    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

    Responsibility for labelling dispensed medicines lies with the regulator, so the service does not provide labelling information.

    Verbatim wording from the response

    “11. The labelling of dispensed medicines is within the remit of the regulator, the General Pharmaceutical Council, who has also been sent a copy of the Regulation 28 Report. The SPS does not provide information regarding the labelling of dispensed medicines.”

    Source location

    Response from Specialist Pharmacy Service
    Page 3 · response
    Published 15 October 2024

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    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

    Dispensing medication is governed by a national pharmacy contract agreed and negotiated nationally, rather than by the local pharmacy committee.

    Verbatim wording from the response

    “In response to your report, it must be noted that the LPC represents local pharmacy contractors in the delivery of specific pharmacy services to patients living in our community, the dispensing of medication falls within a national pharmacy contract which is agreed, and negotiated at a national level.”

    Source location

    Response from Community Pharmacy Thames Valley
    Page 1 · response
    Published 15 October 2024

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    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

    Responsibility for commissioning dispensing medication rests with Frimley ICB, which has raised the matter with NHS England.

    Verbatim wording from the response

    “With respect to this I have escalated the issues raised with Frimley ICB, who have delegated commissioning for the dispensing of medication, who in turn has raised this matter with NHS England. I have also conversed with our national body – Community Pharmacy England.”

    Source location

    Response from Community Pharmacy Thames Valley
    Page 1 · response
    Published 15 October 2024

    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

    Community pharmacies operate as independent contractors under national contracts, limiting direct influence over their processes.

    Verbatim wording from the response

    “I am replying as the Chief Pharmacist for NHS Frimley, responsible for medicines optimisation and pharmacy across our system. While we recognise our duty to address the concerns raised, it is important to note that community pharmacies and other healthcare professionals operate as independent contractors under a national framework or contract, limiting our direct influence over their processes.”

    Source location

    Response from NHS Frimley ICB
    Page 1 · response
    Published 15 October 2024

    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

    Different dosette or label colours are not currently available because community-pharmacy dosettes must meet legal labelling requirements.

    Verbatim wording from the response

    “Dosette boxes are not always or the only solution for supporting a patient in taking their medication. Although various types of dosette boxes are available for purchase by the public, there are only a limited number used within community pharmacy due to the requirement that dosettes used must enable fulfilment of the legal labelling requirements. These are not currently available in different colours or label colours.”

    Source location

    Response from NHS Frimley ICB
    Page 3 · response
    Published 15 October 2024

    Open published response

  2. Suffolk

    AI-generated summary

    Matthew Colin FITTEN · 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

    Matthew Fitten was found deceased at home on 17 April 2020, and toxicology identified a toxic quantity of methadone in his blood. During the COVID-19 pandemic, his methadone collection was changed from three times per week to fortnightly, but he received three large bottles without a measuring jug or instructions for accurately measuring his prescribed daily dose. The report identifies concerns that this increased access to methadone and the lack of suitable dosing arrangements contributed to his death.

    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 dispense prescribed methadone in single daily dosage bottles

    Wider context from the report

    “During the evidence it was heard that at the start of the Covid19 pandemic PHE guidance was issued to Turning Point (the Suffolk Recovery Network) that individuals on opiate replacement treatment (Methadone) should be moved off short term (daily or tri-weekly) prescription collections to longer term ones. In Matthew’s case his collection was changed from 3 times per week to fortnightly. The doctor who made the changes to the prescription stipulated that Matthew’s dose must be in single daily dosage bottles. Matthew had a secure store in his home and was used to taking his Methadone from single daily dosage bottles. In addition the Turning Point doctor had sent a letter to all of the pharmacy’s that supplied opiate replacement therapies to his patients, explaining that only daily usage bottles should be prescribed. On the 15th April 2020 Matthew collected his 14-day methadone supply from the Haverhill Pharmacy in Haverhill, Suffolk. Evidence produced by Matthews father during the inquest itself, clearly showed that Matthew had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of Methadone respectively. In addition, because Matthew’s prescription had been for single dose bottles a separate ‘measuring jug’ had not been prescribed by the Turning Point doctor. Matthew’s prescribed dose of Methadone was 54ml daily. As such, when Matthew was given the 100ml, 156ml and 500ml Methadone bottles on the 15th April 2020, he was not given anything to accurately measure his daily dose from them. It is therefore probable, that due to a lack of a measuring jug, Matthew guessed his first dose from the larger Methadone bottles with tragic consequences. Had Matthew been given daily dose bottles of Methadone as prescribed, or a measuring jug and instructions on how to use it had been provided, on a balance of probability basis his death would not have occurred. ”

    Source location

    Matthew Colin FITTEN · 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

    Develop and publish COVID-19 guidance for drug and alcohol treatment providers addressing infection risks and medication dispensing arrangements.

    Verbatim wording from the response

    “Public Health England’s (PHE's) COVID-19 guidance to the drug and alcohol treatment sector (COVID-19: guidance for commissioners and providers of services for people who use drugs or alcohol) was developed with senior medical, pharmacy and other representatives from the sector, including from Turning Point. The process started from calls with treatment providers on 17 and 18 March 2020 and the guidance was developed until the first iteration was published on 15 April 2020.”

    Source location

    2020-0275-Response-from-Public-Health-England-Redacted
    Page 1 · response
    Published 5 January 2021

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    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

    Strengthen individualised risk-assessment requirements in subsequent iterations of published guidance before changing medication dispensing arrangements.

    Verbatim wording from the response

    “To prevent future deaths, PHE has often reiterated to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements and strengthened these lines in subsequent iterations of its published guidance this year. PHE has also worked closely with the Care Quality Commission (CQC), whose inspectors are actively monitoring registered drug treatment services. The CQC has investigated the changes in practice that the pandemic has required, to make sure that there is no blanket application of these changes.”

    Source location

    2020-0275-Response-from-Public-Health-England-Redacted
    Page 2 · response
    Published 5 January 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

    Reiterate to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements.

    Verbatim wording from the response

    “To prevent future deaths, PHE has often reiterated to drug and alcohol treatment providers the need for individualised risk assessments before changing medication dispensing arrangements and strengthened these lines in subsequent iterations of its published guidance this year. PHE has also worked closely with the Care Quality Commission (CQC), whose inspectors are actively monitoring registered drug treatment services. The CQC has investigated the changes in practice that the pandemic has required, to make sure that there is no blanket application of these changes.”

    Source location

    2020-0275-Response-from-Public-Health-England-Redacted
    Page 2 · response
    Published 5 January 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

    Continue supplying methadone in individual dose containers as the pharmacy’s standard procedure.

    Verbatim wording from the response

    “As explained above that pharmacy may have made supply in bigger bottles than individual dose bottles. This is not the normal practice of the pharmacy. Haverhill pharmacy always ensure safety and wellbeing of patients. April 2020 was an unprecedented time and all pharmacies were dealing with staff issues, supply issues and abuse from patients towards the NHS staff. All these factors may have made the pharmacy supply the methadone not in individual bottles.”

    Source location

    2020-0275-Response-from-Haverhill-Pharmacy-Redacted
    Page 10 · response
    Published 5 January 2021

    Open published response

  3. Swansea and Neath Port Talbot

    AI-generated summary

    Christopher John Llewellyn Roberts · 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

    Christopher John Llewellyn Roberts was pronounced dead at his home on 19 October 2015 after an overdose involving prescribed opiate medication. He was receiving treatment for mental illness, and his medication use was described as chaotic. The report raised concerns that a care plan review was not recorded, including whether a recent overdose attempt had been considered, and that nomad trays may be unsuitable for some patients.

    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

    Unsuitability of Nomad trays for dispensing medication to some patients

    Wider context from the report

    “2. Nomad trays may be unsuitable in dispensing medication to some patients, which may deprive them of the benefits in taking that medication. ”

    Source location

    Christopher John Llewellyn Roberts · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. South Lincolnshire

    AI-generated summary

    Derrick Twaite · 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

    Derrick Twaite swallowed a Finasteride tablet that remained in a sharp-edged bubble-pack segment, causing a gut perforation that led to his death. The report raised concern that tablets were still being snipped from unit-dose packs and placed in multi-dose compliance aids despite advice from relevant professional bodies.

    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 comply with professional advice against placing snipped tablets in multi-dose compliance aids

    Wider context from the report

    “1. That although this practice of snipping tablets from the unit dose packs, still in their bubble, and place them in the compartments of multi-dose compliance aids is contrary to the advice of the relevant professional bodies, it apparently still being done by dispensing pharmacists and dispensing general practices.. ”

    Source location

    Derrick Twaite · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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