Recurring concern

Unreliable pharmacy clinical guidance and procedures

First to latest report 11 May 2016 — 17 May 2024

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
2

What this concern includes

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

What is not included
  • Excludes clinical guidance deficiencies unrelated to pharmacy practice unless the report explicitly identifies a pharmacy-specific guidance or procedure failure.
  • Excludes generic failures to follow clinical guidance where no deficiency in pharmacy guidance, policy or procedure is identified.
  • Excludes pharmacy staffing, resourcing, dispensing, controlled-drug regulation or operational-process failures unless the report directly identifies pharmacy guidance or procedures as the unsafe condition.
  • Excludes guidance omissions concerning unrelated clinical systems, beneficiaries or hazards where no pharmacy-specific guidance boundary is supported.

Reports and published responses 4 reports

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

  1. Greater Lincolnshire

    AI-generated summary

    Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

    “(1) There is a lack of local practitioner guidance on the practical implementation of the NICE NSAIDs - prescribing issues documentation. ”

    Source location

    Jonathan Paul SZCZEPANSKI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Add a reminder about co-prescribing PPIs with NSAIDs to the Lincolnshire Formulary.

    Verbatim wording from the response

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

    Source location

    2024-0271 Response from Lincolnshire Integrated Care Board
    Page 1 · response
    Published 20 May 2024

    Open published response

  2. Suffolk

    AI-generated summary

    Deborah Michelle HEADSPEATH · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

    “3. New guidance from the General Pharmaceutical Council was issued in April 2019 and this includes specific advice regarding on-line prescriptions. This is clearly welcome, however some witnesses highlighted that the guidance is advisory and not mandatory. As such there was some uncertainty as to what sanctions would be available against any supplying pharmacist who chose not to adhere to the new guidance? ”

    Source location

    Deborah Michelle HEADSPEATH · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester North

    AI-generated summary

    Ms Christina Ann Fletcher · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

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

    Wider context from the report

    “1. There is no specific guidance, policy or protocol from the GPhC on the requirement for a ‘red flag’ system within pharmacies in relation to patients with identical names, similar addresses, living in close proximity etc. as demonstrated by the very tragic circumstances of this case. Whilst the Pharmacy in question did have internal processes in place at the time, concern remains that other Pharmacies throughout England and Wales might not, in the absence of specific guidance from their Regulator. ”

    Source location

    Ms Christina Ann Fletcher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Produce guidance for pharmacy owners and superintendent pharmacists on safely providing pharmacy services at a distance, including medicine delivery and staff training.

    Verbatim wording from the response

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

    Source location

    Christina-Fletcher_Redacted
    Page 3 · response
    Published 27 November 2017

    Open published response

  4. Preston and West Lancashire

    AI-generated summary

    Sally Ann Tooze Froggatt · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Corporate pharmacy guideline documentation contradicting NICE guidance

    Wider context from the report

    “3. corporate pharmacy guideline documentation that appears to contradict the NICE guidance referred to in other corporate literature ”

    Source location

    Sally Ann Tooze Froggatt · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

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