Recurring concern

Inadequate safeguards for access to dangerous drugs

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First reported 30 Mar 2015•Latest report 29 Apr 2026

Definition

What this concern includes

Includes failures of controls specifically intended to regulate, authorise, supervise, audit or restrict access to dangerous drugs across healthcare, ambulance, pharmacy, online-supply and comparable drug-access settings, including the anchor's insufficient regulatory safeguards and auditing and failures involving unregulated online supply or pharmacy safeguards.

Not included

  • Excludes generic regulation, auditing or trust concerns where no dangerous-drug access or control issue is identified.
  • Excludes controls for non-drug hazardous items, weapons, chemicals or other substances unless the assertion specifically concerns dangerous drugs or drug supply.
  • Excludes clinical prescribing, administration, monitoring or treatment failures where access or supply control is not the unsafe condition.
  • Excludes the existing narrower concern concerning access to prescription-only medicines outside regulated prescribing when the assertion is specifically limited to that named prescription-only-medicine supply boundary.
Reports
14

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2015–2026

First to latest report issue date

Stated actions
36

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care6
NHS England4
Home Office3
Medicines and Healthcare products Regulatory Agency3
Department for Digital, Culture, Media and Sport2
General Pharmaceutical Council2
General Practitioners Committee UK2
Recipient name withheld2
Advisory Council on the Misuse of Drugs1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Boots UK Limited1
Department for Digital, Culture, Media & Sport (2017 to 2023)1
Department for Science, Innovation and Technology1
National Crime Agency1
NHS Greater Manchester 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.

  1. Birmingham and Solihull

    AI-generated summary

    Name not published · 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

    An experienced Operational Department Practitioner was found deceased in on-call accommodation after deliberately injecting himself with anaesthetic medication accessed from a secure hospital drug store. Concerns were raised that NHS England guidance did not adequately address risk assessment, prompt police notification, suspension decisions, or removal of access to potentially fatal drugs following serious allegations.

    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 NHS England guidance to address prompt decisions on suspension and withdrawal of easy access to fatal drugs

    Wider context from the report

    “1. The Trust level investigation identified concerns that NHS England guidance - e.g. (a) NHS England Misconduct Policy ‘Every organisation has a duty of care to protect its employees from and prevent incidents of sexual misconduct’; and (b) e-learning ‘Understanding Sexual Misconduct in the Workplace’ – omits to deal with how to discuss and manage the alleged perpetrator when a member of staff. It does not cover when the Trust may need to conduct a risk assessment of the likely impact on the staff member of being confronted with a serious allegation, when they may need to inform the police promptly, or advise on what factors impact the need for a prompt decision on suspension and withdrawal of easy access to fatal drugs. Since this incident the local Trust has updated their policies so that a same day decision is made on these matters and in a similar incident in the future it is likely the staff member would have been immediately suspended and had their access to fatal drugs removed. My concern is that NHS England guidance continues to omit such considerations and at a local level Trusts are not fully assessing the risks. ”

    Source location

    Name not published · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  2. Ceredigion

    AI-generated summary

    Christopher Brazil · 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 Brazil had physical pain, sciatica and poor mental health, and sourced additional medicines and drugs from unlawful online providers. He died in August 2022 after unintentionally overdosing on benzodiazepines. The concerns included the accessibility and legitimacy of unregulated websites, unsafe or counterfeit medicines, inadequate checks of medical history, dosage guidance, safeguards, age and identity verification, and rapid delivery.

    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

    Unregulated and unlawful online sale of prescription-only medicines and controlled drugs

    Wider context from the report

    “(1) There are unregulated and unlawful websites offering prescription only medicines and controlled drugs, which look legitimate and are found easily from simple online searches; and these sites give rise to the following points (2) to (6) (2) Vulnerable and susceptible people are exposed to counterfeit or unsafe medications (3) There are insufficient or no measures to verify patient medical history before selling the medication and drugs (4) There is a lack of guidance regarding dosage (5) There are a lack of safeguards to prevent incorrect self-diagnoses or misuse by consumers (6) There is inadequate age and identity verification, potentially allowing minors to access restricted medicines and drugs (7) The fact that it is possible for unlawful and unethical online pharmaceutical providers to operate and deliver to the buyer within 24 hours means that these illegal websites may be more appealing to some than lawful sources. ”

    Source location

    Christopher Brazil · 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

    Enhance collaboration with search engines and UK internet service providers to block harmful content through targeted filtering.

    Verbatim wording from the response

    “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:”

    Source location

    Response from DHSC
    Page 3 · response
    Published 25 April 2025

    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

    Collaborate with Ofcom to explore preventative opportunities under the Online Safety Act.

    Verbatim wording from the response

    “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:”

    Source location

    Response from DHSC
    Page 3 · response
    Published 25 April 2025

    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

    Increase collaboration with UK Border Force to expand border operations and increase seizures of illegally trafficked medicines.

    Verbatim wording from the response

    “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:”

    Source location

    Response from DHSC
    Page 3 · response
    Published 25 April 2025

    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

    Use technology to identify, track and seize proceeds of crime, including cryptocurrency.

    Verbatim wording from the response

    “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:”

    Source location

    Response from DHSC
    Page 3 · response
    Published 25 April 2025

    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

    Roll out an online service enabling users to check whether pharmaceutical-selling websites have been deemed fraudulent by the MHRA.

    Verbatim wording from the response

    “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:”

    Source location

    Response from DHSC
    Page 3 · response
    Published 25 April 2025

    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

    Implement a web-based scheme allowing users to report suspicious websites, marketplaces and social media listings to the MHRA.

    Verbatim wording from the response

    “• Implementation of a web-based reporting scheme allowing users to report suspicious websites, online marketplaces and social media listings to the MHRA.”

    Source location

    Response from DHSC
    Page 4 · response
    Published 25 April 2025

    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

    Collaborate with UK banking and payment providers to disrupt payment mechanisms used by illegal prescription-medicine suppliers.

    Verbatim wording from the response

    “• Collaboration with UK banking and payment providers to disrupt the payment mechanisms used by websites illegally supplying prescription only medicines.”

    Source location

    Response from DHSC
    Page 4 · response
    Published 25 April 2025

    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

    Use artificial intelligence to proactively identify illicit internet domains for enforcement action.

    Verbatim wording from the response

    “• The use of Artificial Intelligence to proactively identify illicit internet domains for enforcement action.”

    Source location

    Response from DHSC
    Page 4 · response
    Published 25 April 2025

    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

    Work with Ofcom to implement the Online Safety Act quickly and effectively.

    Verbatim wording from the response

    “The government recognises that the internet can sometimes be a gateway to content which can lead to devastating consequences. As the Secretary of State for Science, Innovation and Technology, I am responsible for the Online Safety Act (the ‘Act’) which received Royal Assent in 2023. The Act lays the foundation for strong protections against illegal content for all users, and the government is committed to working with Ofcom, the independent regulator, to ensure it is implemented quickly and effectively. The new laws apply to search services and all companies that allow users to post content online or to interact with each other. This includes a broad range of websites, apps and other services, including social media services, consumer cloud storage sites, video sharing platforms, online forums, dating services, and online instant messaging services.”

    Source location

    Response from DSIT
    Page 1 · response
    Published 25 April 2025

    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

    The GPhC, other professional regulators, CQC and MHRA have responsibility and powers to investigate unlawful online providers and take enforcement action.

    Verbatim wording from the response

    “In a situation where an online provider acts unlawfully, the General Pharmaceutical Council (GPhC) and other professional regulators, Care Quality Commission (CQC) and the Medicines and Healthcare products Regulatory Agency (MHRA) have the powers to investigate and take action against prescribers, products and suppliers who do not comply with legislation and national guidance. I would like to assure you that regulators have my full support to crack down on any services putting people in danger.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 25 April 2025

    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

    UK authorities cannot seize or control illicit overseas domains or compel registrars to suspend them, especially beyond UK jurisdiction.

    Verbatim wording from the response

    “The sale and supply of unregulated medicinal products is a global problem. Online portals play a significant role in transnational medicines crime and many websites proliferate across the internet. Currently, there is no legal mechanism for UK law enforcement to seize or control of illicit overseas domains or compel internet registrars to suspend them. Gaining regulatory compliance can be a difficult and sometimes impossible process, especially when domains are registered beyond the reach of UK jurisdiction.”

    Source location

    Response from DHSC
    Page 3 · response
    Published 25 April 2025

    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

    Regulation of medicines and devices, including unlawful prescription-medicine websites, is largely outside the department’s remit.

    Verbatim wording from the response

    “In your letter, you raise concerns around unregulated and unlawful websites offering prescription only medicines and controlled drugs. These matters of concern are largely within the remit of the Medicines and Healthcare products Regulatory Agency (MHRA), given their responsibility for the regulation of medicines and devices in the UK. I understand that they are responding to you separately outlining their approach. Additionally, MHRA have informed my department that they have already taken enforcement action on both websites referenced in your report and are seeking to stop UK users being able to access such sites. One of the websites is subsequently offline, and the other is in the process of being taken offline to protect the public from the illegal sale of medicines.”

    Source location

    Response from DSIT
    Page 1 · response
    Published 25 April 2025

    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

    The MHRA is responsible for addressing the unlawful websites and will respond separately about its approach.

    Verbatim wording from the response

    “In your letter, you raise concerns around unregulated and unlawful websites offering prescription only medicines and controlled drugs. These matters of concern are largely within the remit of the Medicines and Healthcare products Regulatory Agency (MHRA), given their responsibility for the regulation of medicines and devices in the UK. I understand that they are responding to you separately outlining their approach. Additionally, MHRA have informed my department that they have already taken enforcement action on both websites referenced in your report and are seeking to stop UK users being able to access such sites. One of the websites is subsequently offline, and the other is in the process of being taken offline to protect the public from the illegal sale of medicines.”

    Source location

    Response from DSIT
    Page 1 · response
    Published 25 April 2025

    Open published response
  3. Hampshire, Portsmouth and Southampton

    AI-generated summary

    John Robert ELLIS · 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

    John Robert ELLIS, a veterinary surgeon experiencing personal, financial and work-related stress, died after self-administering a toxic quantity of a drug he had obtained by falsely claiming it was needed to euthanise a dog. The principal concern was that veterinary surgeons could access potentially lethal controlled drugs without adequate verification, scrutiny or safeguards against misuse.

    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 verify the stated need for potentially lethal drugs through independent veterinary scrutiny

    Wider context from the report

    “Veterinary surgeons, such as the deceased, are able to easily access potentially lethal drugs, such as ████████ (which is a Schedule 3 Controlled Drug) without any adequate controls being put in place to prevent their misuse. The deceased in this case was able to invent a story to the effect that he needed the drug in order to carry out a home visit, the purported purpose of which was to euthanise a large dog. He was given 50ml of ████████ by his former employers, without any checks having first been made to verify his account of why it was needed and without scrutiny by another veterinary surgeon. He was allowed to walk out of the veterinary surgery unaccompanied, with the drug, which he then used to take his own life by means of an intravenous drip. ”

    Source location

    John Robert ELLIS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 adequate controls over veterinary surgeons' access to potentially lethal drugs

    Wider context from the report

    “Veterinary surgeons, such as the deceased, are able to easily access potentially lethal drugs, such as ████████ (which is a Schedule 3 Controlled Drug) without any adequate controls being put in place to prevent their misuse. The deceased in this case was able to invent a story to the effect that he needed the drug in order to carry out a home visit, the purported purpose of which was to euthanise a large dog. He was given 50ml of ████████ by his former employers, without any checks having first been made to verify his account of why it was needed and without scrutiny by another veterinary surgeon. He was allowed to walk out of the veterinary surgery unaccompanied, with the drug, which he then used to take his own life by means of an intravenous drip. ”

    Source location

    John Robert ELLIS · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 prevent unaccompanied removal of potentially lethal drugs from the veterinary surgery

    Wider context from the report

    “Veterinary surgeons, such as the deceased, are able to easily access potentially lethal drugs, such as ████████ (which is a Schedule 3 Controlled Drug) without any adequate controls being put in place to prevent their misuse. The deceased in this case was able to invent a story to the effect that he needed the drug in order to carry out a home visit, the purported purpose of which was to euthanise a large dog. He was given 50ml of ████████ by his former employers, without any checks having first been made to verify his account of why it was needed and without scrutiny by another veterinary surgeon. He was allowed to walk out of the veterinary surgery unaccompanied, with the drug, which he then used to take his own life by means of an intravenous drip. ”

    Source location

    John Robert ELLIS · 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

    Issue guidance requiring veterinary surgeons and nurses to securely lock away schedule 3 barbiturates.

    Verbatim wording from the response

    “11. In light of the known risk factors, the RCVS consistently goes beyond what is required by legislation with the aim of reducing misuse of drugs, including controlled drugs. For example, although quinabibartone (aka Somulose) is a schedule 2 controlled drug (CD), it is exempted from the safe custody in the legislation. In February 2023, we issued guidance requiring that veterinary surgeons and veterinary nurses lock quinalbarbitone away in a manner equivalent to ‘safe custody’, i.e. specific requirements for safe storage of certain CDs as set out in the regulations cited above. Similarly, the barbiturates (including ████████) are schedule 3 CDs and as such, not subject to safe custody under the relevant legislation. Again, in 2021 we issued guidance requiring veterinary surgeons and veterinary nurses to securely lock them away.”

    Source location

    Response from RCVS
    Page 2 · response
    Published 15 November 2024

    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

    Advise practices to return controlled drugs to their controlled-drugs cabinet for overnight storage wherever possible.

    Verbatim wording from the response

    “12. In addition, we advise that, wherever possible, controlled drugs should be returned to the controlled drugs cabinet at the practice for storage overnight. (See Practice Standards Scheme standards, 10.1.12 (small animal), 8.1.12 (farm animal), 9.1.12 (equine)).”

    Source location

    Response from RCVS
    Page 2 · response
    Published 15 November 2024

    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 schedule 2 controlled-drug legislative requirements and decide whether provisions should be extended to schedule 3 drugs through RCVS guidance.

    Verbatim wording from the response

    “17. As required by the report, we have reviewed the existing measures in place to prevent future deaths and assessed what more could be done. Following this review, the actions set out in the table below have been agreed.”

    Source location

    Response from RCVS
    Page 3 · response
    Published 15 November 2024

    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 engaging with the Home Office on implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine.

    Verbatim wording from the response

    “5 | Continue to engage with the Home Office in respect of implementing additional safeguards for controlled drugs used for euthanasia in veterinary medicine. | Ongoing”

    Source location

    Response from RCVS
    Page 4 · response
    Published 15 November 2024

    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 guidance on returning controlled drugs to practices when veterinary professionals are off duty.

    Verbatim wording from the response

    “17. As required by the report, we have reviewed the existing measures in place to prevent future deaths and assessed what more could be done. Following this review, the actions set out in the table below have been agreed.”

    Source location

    Response from RCVS
    Page 3 · response
    Published 15 November 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

    A universal two-person rule for euthanasia drugs is impractical for rural and ambulatory practitioners and could harm animal welfare.

    Verbatim wording from the response

    “14. As you will appreciate, access to and knowledge of how to use lethal medicines is a necessary part of a veterinary surgeon’s role. As such, in terms of barriers to access, there is a balance to be struck between keeping the veterinary team safe and ensuring animal health and welfare is protected. For example, one suggestion has been that the RCVS should”

    Source location

    Response from RCVS
    Page 2 · response
    Published 15 November 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

    The Home Office is responsible for controlled-drugs legislation, and the Veterinary Medicines Directorate cannot change it.

    Verbatim wording from the response

    “However, we should explain that the Home Office is responsible for the legislation regarding controlled drugs. That includes controlled drugs used for veterinary purposes and/or human use. The VMD has no regulatory powers to make changes to controlled drugs legislation.”

    Source location

    Response from Veterinary Medicines Directorate
    Page 1 · response
    Published 15 November 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

    The Home Office is responsible for the legislation governing controlled drugs.

    Verbatim wording from the response

    “10. Regarding veterinary medicines, it should be noted that many of the requirements around controlled drugs are set out in the Misuse of Drugs Act 1971, the Misuse of Drugs Regulations 2001 and the Misuse of Drugs (Safe Custody) Regulations 1973. As you will know, the Home Office is the relevant government department with responsibility for this legislation.”

    Source location

    Response from RCVS
    Page 2 · response
    Published 15 November 2024

    Open published response
  4. East London

    AI-generated summary

    David John Morris · 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

    David John Morris, aged 78, developed oesophageal cancer after delays in diagnosis and treatment, later undergoing gastrostomy surgery. He developed a gastrostomy leak, peritonitis and septic shock, and died in hospital on 16 May 2022 after further surgery. The concerns included delayed recognition and treatment of the leak and sepsis, poor clinical records, deficiencies in the investigation, and ineffective controlled-drug management systems.

    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

    Ineffective controlled drug management systems for detecting prolonged theft and self-administration

    Wider context from the report

    “5. The Trust did not have effective controlled drug management systems in place to detect a prolonged and persistent course of conduct from an employed nurse who was stealing and self- administering controlled drugs in the workplace. ”

    Source location

    David John Morris · Prevention of Future Deaths report
    Page 3 · 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

    Trial a digital key system on each ward for controlled medication management.

    Verbatim wording from the response

    “In light of the concerns raised by the learned Coroner, the Trust is trialing a digital key system on each ward, together with exploring installing CCTV into the Medicine Preparation rooms. An initial discussion with suppliers took place in July 2024.”

    Source location

    2024-0360 - Response from Barking Havering and Redbridge NHS Trust
    Page 3 · response
    Published 4 July 2024

    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

    Explore installing CCTV in medicine preparation rooms.

    Verbatim wording from the response

    “In light of the concerns raised by the learned Coroner, the Trust is trialing a digital key system on each ward, together with exploring installing CCTV into the Medicine Preparation rooms. An initial discussion with suppliers took place in July 2024.”

    Source location

    2024-0360 - Response from Barking Havering and Redbridge NHS Trust
    Page 3 · response
    Published 4 July 2024

    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

    Introduce a Medicine Management Nurse role to support compliance with medication policies.

    Verbatim wording from the response

    “To assist with compliance with the medication policies, a Medicine Management Nurse is being introduced within the Trust and the recruitment process is currently underway. Advertising of the post should begin in October 2024 with appointment following this.”

    Source location

    2024-0360 - Response from Barking Havering and Redbridge NHS Trust
    Page 3 · response
    Published 4 July 2024

    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

    Assign sole responsibility and ownership for Controlled Medication Keys to identified individuals at the start of each shift.

    Verbatim wording from the response

    “A change in the process of Controlled Medication Keys is already in place since the incident, with individuals identified at the start of each shift with sole responsibility and ownership of these.”

    Source location

    2024-0360 - Response from Barking Havering and Redbridge NHS Trust
    Page 3 · response
    Published 4 July 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

    The Trust will respond separately to the concerns about care and processes.

    Verbatim wording from the response

    “I understand that the Barking, Havering & Redbridge University Trust will also be responding separately to your concerns and that the London region of NHS England is”

    Source location

    2024-0360 - Response from DHSC
    Page 1 · response
    Published 4 July 2024

    Open published response
  5. Rutland and North Leicestershire

    AI-generated summary

    Nigel Walter DIXON · 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

    Nigel Walter Dixon, a 64-year-old man who lived alone, was found dead at home on 13 February 2023 after being unable to be roused. His cause of death was morphine and Zopiclone toxicity. Concerns included his access to morphine after hospital discharge and the online supply of large quantities and dosages of Zopiclone without adequate checks, communication with his GP, or safeguards.

    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

    Sale of online drugs in doses and quantities larger than ordinarily prescribed

    Wider context from the report

    “Mr Dixon was able to purchase ████████ Zopiclone tablets ████████ online from a company ████████ The GP who gave evidence at the inquest described this as a “huge” amount of the drug. She confirmed that she would only prescribe 28 days’ worth of ████████ tablets in one go (████████ Mr Dixon was able to purchase). The selling of tablets which are a larger dose and in a much larger quantity than would ordinarily be prescribed online risks an accidental or intentional overdose of the drug and also risks the drug being sold on the black market. ”

    Source location

    Nigel Walter DIXON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 regulation of online supply of powerful drugs

    Wider context from the report

    “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites, there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all. There seems to be no system for establishing the suitability of the purchaser, nor a system to limit the amount or frequency of medication being purchased. ”

    Source location

    Nigel Walter DIXON · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    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 control duplicate, excessive or frequent online drug purchases

    Wider context from the report

    “It is gravely concerning that powerful drugs are available online so freely and in such large quantities, with little to nothing in the way of checks and balances around who the drugs are being sold to. There seems to be no regulation of the supply of these drugs and that seems to me to inevitably put the lives of vulnerable people at risk. In this case there was no communication with Mr Dixon’s GP and I would imagine there is no way for these online companies to check whether their customers are placing duplicate orders with other websites, there seems therefore to be a situation where one could purchase almost limitless amounts of these drugs with no checks or balances at all. There seems to be no system for establishing the suitability of the purchaser, nor a system to limit the amount or frequency of medication being purchased. ”

    Source location

    Nigel Walter DIXON · Prevention of Future Deaths report
    Page 3 · 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

    Investigate the illicit website through the MHRA criminal enforcement process.

    Verbatim wording from the response

    “The MHRA can confirm that the website in question is subject to an active criminal investigation, and that arrests had been made prior to the issuing of the Regulation 28 Report. The MHRA has also issued multiple formal requests to the registrar (the company that manages the website's domain name) to suspend the website, which has thus far been unsuccessful. Other MHRA efforts to minimise the risk this website poses to the public have included:”

    Source location

    Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
    Page 2 · response
    Published 14 June 2024

    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

    Disrupt access to the illicit website through search-engine delisting, parental-control blocking, industry referrals and registry takedown requests.

    Verbatim wording from the response

    “The MHRA can confirm that the website in question is subject to an active criminal investigation, and that arrests had been made prior to the issuing of the Regulation 28 Report. The MHRA has also issued multiple formal requests to the registrar (the company that manages the website's domain name) to suspend the website, which has thus far been unsuccessful. Other MHRA efforts to minimise the risk this website poses to the public have included:”

    Source location

    Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
    Page 2 · response
    Published 14 June 2024

    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

    Develop targeted ISP filtering with search engines and UK internet service providers to block harmful online medicines content.

    Verbatim wording from the response

    “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:”

    Source location

    Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
    Page 3 · response
    Published 14 June 2024

    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

    Explore preventative online-safety measures with Ofcom under the Online Safety Act.

    Verbatim wording from the response

    “Through a combination of public empowerment, technological innovation, traditional methods of law enforcement and close collaboration with partners, the MHRA is constantly working to develop new and innovative ways to tackle the online trade in illegal medicines. Some of these future criminal countermeasures will include:”

    Source location

    Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
    Page 3 · response
    Published 14 June 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 the unregistered overseas supplier falls to the MHRA rather than the General Pharmaceutical Council.

    Verbatim wording from the response

    “The GPhC regulates pharmacists, pharmacy technicians and pharmacies in Great Britain. The company ████████ is not a business registered with the GPhC and operates outside the UK jurisdiction. As such, this matter falls to the MHRA.”

    Source location

    Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
    Page 1 · response
    Published 14 June 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

    UK law enforcement cannot seize or compel suspension of illicit domains registered beyond UK jurisdiction.

    Verbatim wording from the response

    “However, the sale and supply of unregulated medicinal products is a global problem. Online portals play a significant role in transnational medicines crime and many websites proliferate across the internet. Currently, there is no legal mechanism for UK law enforcement to seize control of illicit domains or compel registrars to suspend them when domains are registered beyond the reach of UK jurisdiction. The website referenced in the Regulation 28 notice falls into this category, being registered outside of the UK.”

    Source location

    Joint response from DHSC and Department of Science Information and Technology (on behalf of DCMS)
    Page 2 · response
    Published 14 June 2024

    Open published response
  6. Cheshire

    AI-generated summary

    Adrian Brendan GALLAGHER · 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

    Adrian Gallagher was found deceased in bed on 10 November 2017 after being admitted to Hollins Park Hospital and receiving periods of unsupervised leave. His death was due to an intentional overdose and the inquest concluded that it was suicide. Concerns included the online availability of materials and drugs that could assist suicide, limited age and identity checks, and access by vulnerable mental health 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

    Online sale of drugs for ending life

    Wider context from the report

    “████████ is available to anyone to purchase online, directly from the company. The company appears to have some link to the UK as there is a UK helpline number. The ████████ appears to provide step by step instruction on how to end your life using certain methods, including how to make the death appear to be due to natural causes and therefore avoid referral to the coroner. Whilst the introduction suggests it is aimed at those who are elderly and long-term suffering, there is also reference to suicide for other reasons within the book and is likely to appear to vulnerable mental health patients. According to the evidence of the police officer, you can also buy drugs to end your life through this website. The only check on age and ID appears to be after a purchase, to allow you access to online forums where you can get further advice on best methods. The ████████ has been banned in Australia (and possibly other countries) as it is deemed to encourage/ assist in suicide. The ████████, in some format, is also available on Amazon (and I am writing to Amazon directly to flag this). ”

    Source location

    Adrian Brendan GALLAGHER · 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

    Seek to tackle suppliers of harmful substances intended for suicide at source.

    Verbatim wording from the response

    “The Government is taking a leading role in tackling methods of suicide, collaborating with partners across the world in policy, law enforcement and society more broadly to limit access, and share research, evidence and lessons learned. This includes seeking to tackle at source the suppliers of harmful substances for the purposes of suicide.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 11 January 2024

    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

    Operate measures to reduce awareness of and limit access to suicide methods, including the method involved in the death.

    Verbatim wording from the response

    “The Department of Health and Social Care leads a cross-sector, cross-government working group to tackle emerging methods, working with those partners. As a result of this group, there are now very active actions in place to reduce awareness and limit access to methods of suicide, including the one used by Mr Gallagher. The group meets regularly and remains vigilant to any further methods that we receive intelligence on, and will not hesitate to act should it be required.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 11 January 2024

    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

    Lead a cross-sector, cross-government working group that meets regularly to address emerging suicide methods and remain vigilant to new intelligence.

    Verbatim wording from the response

    “The Department of Health and Social Care leads a cross-sector, cross-government working group to tackle emerging methods, working with those partners. As a result of this group, there are now very active actions in place to reduce awareness and limit access to methods of suicide, including the one used by Mr Gallagher. The group meets regularly and remains vigilant to any further methods that we receive intelligence on, and will not hesitate to act should it be required.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 11 January 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

    DSIT is responsible for explaining how the Online Safety Act will address illegal and harmful suicide and self-harm content.

    Verbatim wording from the response

    “The Department for Science, Innovation and Technology (DSIT) will respond outlining how the Online Safety Act will address illegal and harmful self-harm and suicide content. The Department of Health and Social Care will continue to work closely with DSIT and Ofcom to support this work. We will also continue our support of programmes such as the Samaritans’ Online Excellence Programme, which provides support and guidance for some of the biggest online platforms.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 11 January 2024

    Open published response
  7. Manchester North

    AI-generated summary

    Charlene 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

    Charlene Roberts died at Fairfield General Hospital on 12 January 2023 after suffering cardiac arrest during an inpatient admission; her cause of death was confirmed as cyclizine toxicity, with aspiration pneumonia, anorexia and factitious disorder also recorded. The principal concerns included the availability and prescribing of cyclizine, limited professional understanding of cyclizine dependence and the use of local intelligence systems for non-controlled drugs, and the lack of a commissioned community pathway for obtaining blood samples from compromised 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

    Failure to enforce pharmacy questioning and pharmacist presence for over-the-counter cyclizine purchases

    Wider context from the report

    “The court heard evidence that intravenous cyclizine is by prescription only but oral cyclizine can be purchased over the counter at a pharmacy. In order to purchase oral cyclizine in a pharmacy a pharmacist should seek information as to why it is required and should be present. Charlene’s family gave evidence that following Charlene’s death they had been able to obtain cyclizine in a pharmacy directly from a pharmacy assistant with no questions being asked of them. ”

    Source location

    Charlene Roberts · 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 cyclizine safety, including misuse evidence and this case, to determine whether current risk-minimisation measures remain sufficient.

    Verbatim wording from the response

    “The MHRA keeps the safe and effective use of medicines, including cyclizine, under continual review. We will consider the case raised in this report as well as wider evidence regarding the misuse of cyclizine and determine whether the current risk minimisation measures are sufficient. If further action is required, we will communicate this to healthcare professionals and patients.”

    Source location

    Response from MHRA
    Page 2 · response
    Published 12 December 2023

    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

    Clinical practice, including pharmacy information and patient consultation, is outside the respondent’s remit.

    Verbatim wording from the response

    “While we work closely with healthcare system partners, clinical practice is not within the remit of the MHRA. We would consider that concerns regarding the information provided by the pharmacy when patients request to purchase cyclizine without a prescription, and any consultation patients should receive, would be relevant to raise with the General Pharmaceutical Council, or GPhC, who are responsible for the regulation of the pharmacy profession, or the Care Quality Commission, or CQC, who regulate health and social care in the UK.”

    Source location

    Response from MHRA
    Page 2 · response
    Published 12 December 2023

    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

    Concerns about pharmacy information and patient consultation should be raised with the GPhC or CQC, which regulate relevant services.

    Verbatim wording from the response

    “While we work closely with healthcare system partners, clinical practice is not within the remit of the MHRA. We would consider that concerns regarding the information provided by the pharmacy when patients request to purchase cyclizine without a prescription, and any consultation patients should receive, would be relevant to raise with the General Pharmaceutical Council, or GPhC, who are responsible for the regulation of the pharmacy profession, or the Care Quality Commission, or CQC, who regulate health and social care in the UK.”

    Source location

    Response from MHRA
    Page 2 · response
    Published 12 December 2023

    Open published response
  8. Cornwall and Isles of Scilly

    AI-generated summary

    Helen Spicer · 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

    Helen Spicer died at Royal Cornwall Hospital Truro on 4 October 2018 from an unintentional overdose of prescription morphine, against a background of opiate dependency and chronic pain due to fibromyalgia. The report raised concerns about the absence of restrictions and safe-custody requirements for oral morphine, including the lack of a requirement for collection from a community pharmacy to be signed for.

    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 restrictions on the import, export, possession or administration of oral morphine

    Wider context from the report

    “The absence of restrictions on the import, export, possession or administration of oral morphine, and the fact that safe custody requirements do not apply to them, including the need for them to be signed for when collecting from a community pharmacy. ”

    Source location

    Helen Spicer · Prevention of Future Deaths report
    Page 3 · 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 Home Office takes decisions on controlled-drug scheduling, informed by advice from the Advisory Council on the Misuse of Drugs.

    Verbatim wording from the response

    “Decisions on the scheduling of controlled drugs under the relevant legislation are taken by the Home Office. This is done with the provision of advice from the Advisory Council on the Misuse of Drugs (ACMD), and any decisions made by the ACMD weigh up the risks of misuse, abuse and diversion, against not impeding legitimate use within healthcare.”

    Source location

    2021-0127-Response-from-Department-of-Health-and-Social-Care_Published
    Page 1 · response
    Published 4 May 2021

    Open published response
  9. London Inner (West)

    AI-generated summary

    Michael Lobban · 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

    Michael Lobban, who had drug dependency and mental illness, was found dead at home on 23 October 2017 with a significant methadone overdose and other drugs in his body. The report raised concerns about the speed and completeness of Boots’ investigation into missing methadone, the robustness of its controlled-drug audit procedures, and the General Pharmaceutical Council’s reporting and investigative arrangements for discrepancies in 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 sanctions for pharmacies mislaying controlled drugs

    Wider context from the report

    “4. The General Pharmaceutical Council (“The Council”) being the Regulator of Pharmaceutical industry in England and Wales does not have any reporting requirements for pharmacies when discovering a discrepancy in schedule 2 controlled drugs. Moreover there appear to be no investigative powers by The Council where it discovers a disparity of these controlled drugs and as a consequence there are no sanctions in circumstances where pharmacies have mislaid drugs during the course of their handling of controlled drugs. ”

    Source location

    Michael Lobban · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 physical checking of prescription-box contents during controlled-drug audits

    Wider context from the report

    “3. There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs. ”

    Source location

    Michael Lobban · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Inner West London

    AI-generated summary

    Jennifer Anne Lacey · 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

    Jennifer Anne Lacey was found deceased in a hotel room in Morden on 4 June 2018, having consumed a large amount of alcohol and 210 tramadol tablets. The concerns were that potentially dangerous and addictive drugs were freely available over the internet, could be prescribed without contact with the patient’s regular doctor or access to medical records, and might be dispensed by UK pharmacies without further checks.

    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

    Unrestricted internet availability of potentially dangerous and addictive drugs

    Wider context from the report

    “1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”

    Source location

    Jennifer Anne Lacey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 perform further checks when filling prescriptions for potentially dangerous and addictive drugs in UK pharmacies

    Wider context from the report

    “1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”

    Source location

    Jennifer Anne Lacey · 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 other health regulators to address patient-safety risks from remote consultations and distance-selling medicine supply.

    Verbatim wording from the response

    “With regard to this case, and based on the information provided within the Regulation 28, it appears that this death was not the result of services provided by NHS, but from services outside of the NHS. It is unclear whether this doctor or company were registered and the site from which the deceased obtained the consultation, prescription and medication. Nevertheless, the provision of remote consultations and the supply of medicines through distance selling remains a concern. We are working with other health regulators who have a greater role in responding to this challenge.”

    Source location

    2018-0315-Response-by-NHS-England
    Page 3 · response
    Published 23 February 2019

    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

    The death appears unrelated to NHS services because the consultation, prescription and medication were obtained outside the NHS.

    Verbatim wording from the response

    “With regard to this case, and based on the information provided within the Regulation 28, it appears that this death was not the result of services provided by NHS, but from services outside of the NHS. It is unclear whether this doctor or company were registered and the site from which the deceased obtained the consultation, prescription and medication. Nevertheless, the provision of remote consultations and the supply of medicines through distance selling remains a concern. We are working with other health regulators who have a greater role in responding to this challenge.”

    Source location

    2018-0315-Response-by-NHS-England
    Page 3 · response
    Published 23 February 2019

    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

    CQC and MHRA are better placed to explain and address online prescribing safety work.

    Verbatim wording from the response

    “NHS England remains committed to improving the safety of controlled drugs and online prescribing. We will continue to work across the system with key partners nationally, regionally and locally to ensure patient safety. We would also suggest that contact is made directly with the CQC and MRHA would be better placed should you wish to understand the work in this area further.”

    Source location

    2018-0315-Response-by-NHS-England
    Page 3 · response
    Published 23 February 2019

    Open published response
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Data last updated 7 September 2026