Recurring concern

Unreliable prescription collection and delivery arrangements

First to latest report 24 Oct 2017 — 8 Mar 2022

Reports that mention this concern: 3
Times this concern has been raised: 6
Stated actions linked to this concern: 8

What this concern includes

Includes failures in arrangements for requesting, collecting, delivering, confirming receipt of or responding to failed delivery of prescriptions, including repeat prescriptions and coordination with pharmacies, where the deficiency can interrupt access to important medication.

What is not included

Excludes medication prescribing, dispensing, administration or clinical-review failures where prescription collection or delivery is not the deficient control.
Excludes general medication shortages or supply interruptions not caused by unreliable prescription collection, delivery or pharmacy-coordination arrangements.
Excludes hospital-issued prescription fulfilment where the assertion is limited to a separate hospital discharge or hospital-prescription process.
Excludes generic communication, record-keeping or continuity-of-care deficiencies unless they directly impair prescription collection, delivery or failed-delivery response.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Boots UK Limited1

Egton Medical Information Systems Limited1

Fitzalan Medical Group1

National Institute for Health and Care Excellence1

NHS Surrey and Sussex Integrated Care Board1

Royal College of General Practitioners1

Waythrough1

Reports and published responses 3 reports

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

8 Mar2022
County Durham and Darlington
Concerns raised4
1. Lack of a mechanism to remedy failed delivery
2. Lack of an effective mechanism for immediate detection of failed delivery
3. Failure to witness or confirm delivery
1. Reliance upon delivery of a physical prescription document
Linked responses

Boots UK Limited
Waythrough
Stated actions 8
1. Waythrough
  Agree contingency plans for failed deliveries and escalate unresolved issues to the Area Manager and Clinical Lead.
2. Waythrough
  Provide Saturday morning service availability to remedy unresolved Friday prescription deliveries and maintain weekend provision.
3. Boots UK Limited
  Remind pharmacists to direct patients to local hospital Accident & Emergency teams when FP10MDA problems arise outside clinic hours.
1. Waythrough
  Require failed delivery attempts to be reported immediately by telephone to a nominated on-site manager using prearranged contact details.
2. Waythrough
  Record failed prescription deliveries in the incident system, notify relevant staff, review incidents and identify learning to prevent recurrence.
3. Boots UK Limited
  Encourage treatment clinics to contact pharmacies and confirm receipt of posted FP10MDA forms.
4. Waythrough
  Require prescription deliveries to pharmacies to be made directly to staff, with recipient details, signature, returned paperwork and management-system records.
5. Waythrough
  Escalate the lack of electronic FP10 MDA prescription functionality through relevant national and professional networks.
Respondent positions 6
1. Boots UK Limited
  Pharmacies cannot supply Schedule 2 medication after failed FP10MDA delivery without a replacement paper prescription, including through emergency supply.
  Unable to act
1. Boots UK Limited
  Outside clinic hours, pharmacists have no route to contact a prescriber familiar with the patient and request an urgent replacement prescription.
  Unable to act
2. Boots UK Limited
  Treatment clinics or service commissioners, rather than Boots, would need to require witnessed delivery and monitor failed prescription deliveries.
  Redirects responsibility
3. Boots UK Limited
  Pharmacies cannot detect failed deliveries because patients may choose any community pharmacy for dispensing.
  Unable to act
4. Waythrough
  Electronic transfer of controlled-drug instalment prescriptions is unavailable nationally, so physical prescriptions remain unavoidable until functionality is developed.
  Unable to act
5. Boots UK Limited
  Electronic prescribing is unavailable for FP10MDA instalment prescriptions, leaving paper forms as the only legal mechanism.
  Unable to act
AI-generated summary

Claire COPELAND · 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

Claire Copeland had a break in the continuity of her drug addiction treatment after a physical prescription was delivered unsuccessfully, leaving her unable to obtain medication for the weekend. The inquest concluded that she subsequently consumed drugs, including heroin, and that her death was drug-related. The report identified concerns that the prescription delivery arrangements lacked confirmation, prompt detection of failed delivery, and a fail-safe mechanism to remedy it, creating a risk of discontinuity of important medical treatment.

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 a mechanism to remedy failed delivery
Wider context from the report
“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”
Source location
Claire COPELAND · 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 an effective mechanism for immediate detection of failed delivery
Wider context from the report
“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”
Source location
Claire COPELAND · 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 witness or confirm delivery
Wider context from the report
“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”
Source location
Claire COPELAND · 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
Reliance upon delivery of a physical prescription document
Wider context from the report
“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”
Source location
Claire COPELAND · 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
Agree contingency plans for failed deliveries and escalate unresolved issues to the Area Manager and Clinical Lead.

Verbatim wording from the response
“During the telephone contact between the team member attempting to deliver the prescription and nominated manager a contingency plan will be agreed. This plan will take into account the individual circumstances of the delivery including known pharmacy availability and the timescale requirement of dispensing from the prescription. Continuity of care for the service user and safe prescription management will be equally paramount in agreeing a course of action. If an effective contingency plan cannot be immediately agreed, the issue will be escalated to the service Area Manager and Clinical Lead for further guidance and resolution.”

Source location
Response from HumanKind
Page 2 · response
Published 10 March 2022
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
Provide Saturday morning service availability to remedy unresolved Friday prescription deliveries and maintain weekend provision.

Verbatim wording from the response
“For any failed deliveries on a Friday that cannot be resolved on that day, the service is available on a Saturday morning, enabling an opportunity to remedy delivery and ensure provision for the weekend.”

Source location
Response from HumanKind
Page 2 · response
Published 10 March 2022
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
Remind pharmacists to direct patients to local hospital Accident & Emergency teams when FP10MDA problems arise outside clinic hours.

Verbatim wording from the response
“Boots will remind its pharmacists that, where any problems regarding FP10MDA forms are reported outside of clinic hours, patients must be directed to the Accident & Emergency team at a local hospital, so that an appropriate prescriber can review the patient’s circumstances and consider providing an interim prescription, pending the clinic reopening.”

Source location
Response from Boots UK
Page 2 · response
Published 10 March 2022
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
Require failed delivery attempts to be reported immediately by telephone to a nominated on-site manager using prearranged contact details.

Verbatim wording from the response
“The service’s prescription delivery standard operating procedure states that should it not be possible to directly deliver and confirm delivery of a prescription, the team member should return to their vehicle and make telephone contact with a nominated manager who is on-site within the service base.”

Source location
Response from HumanKind
Page 2 · response
Published 10 March 2022
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
Record failed prescription deliveries in the incident system, notify relevant staff, review incidents and identify learning to prevent recurrence.

Verbatim wording from the response
“Any failed delivery attempt of a prescription is recorded as an incident within Humankind’s incident management system. This system notifies all relevant managers and team members of the incident, creates a review process and supports identification of learning to prevent further occurrences.”

Source location
Response from HumanKind
Page 2 · response
Published 10 March 2022
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
Encourage treatment clinics to contact pharmacies and confirm receipt of posted FP10MDA forms.

Verbatim wording from the response
“However, Boots will encourage clinics to contact the pharmacies to confirm receipt where FP10MDA forms are posted to try and avoid the risk of future failed deliveries.”

Source location
Response from Boots UK
Page 2 · response
Published 10 March 2022
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
Require prescription deliveries to pharmacies to be made directly to staff, with recipient details, signature, returned paperwork and management-system records.

Verbatim wording from the response
“A comprehensive standard operating procedure for all team members delivering prescriptions to pharmacies has been implemented. This includes the mandatory requirement for prescriptions to be handed directly to a member of the pharmacy staff team, obtaining details of the person taking receipt and a signature from that person to confirm delivery. Completed paperwork is returned to the service base and stored for reference and also included within the service’s management information system.”

Source location
Response from HumanKind
Page 1 · response
Published 10 March 2022
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
Escalate the lack of electronic FP10 MDA prescription functionality through relevant national and professional networks.

Verbatim wording from the response
“Further to this, at this time there is no functionality for the electronic transfer of FP10 MDA blue instalment prescriptions. This is a national issue and not specific to Humankind/Spectrum/County Durham Drug and Alcohol Recovery Service. Humankind have continued to escalate this issue, for example with Controlled Drugs Local Intelligence Networks and the Office of Health Inequalities and Disparities, especially during the COVID-19 pandemic where the ongoing need for this to be resolved became especially pertinent.”

Source location
Response from HumanKind
Page 1 · response
Published 10 March 2022
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
Pharmacies cannot supply Schedule 2 medication after failed FP10MDA delivery without a replacement paper prescription, including through emergency supply.

Verbatim wording from the response
“As noted under (1) above, the supply of a Schedule 2 Controlled Drug from community pharmacies is governed by the Human Medicines Regulations 2012 and the Misuse of Drugs Regulations 2001 (as amended). A pharmacy is not permitted in law to provide medication (including an emergency supply), where there is a failed delivery of an FP10MDA form, unless a replacement paper FP10MDA form is provided.”

Source location
Response from Boots UK
Page 2 · response
Published 10 March 2022
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
Outside clinic hours, pharmacists have no route to contact a prescriber familiar with the patient and request an urgent replacement prescription.

Verbatim wording from the response
“Community pharmacies typically provide dispensing services, including the dispensing of methadone for the treatment of addiction, for more hours each week than the clinics are available. When a problem with an FP10MDA form (including a missing prescription) is detected outside of clinic hours, there is no route for a pharmacist to contact one of its prescribers (who will be familiar with the patient’s medical history) and request an urgent replacement prescription.”

Source location
Response from Boots UK
Page 2 · response
Published 10 March 2022
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
Treatment clinics or service commissioners, rather than Boots, would need to require witnessed delivery and monitor failed prescription deliveries.

Verbatim wording from the response
“This would be within the power of individual treatment clinics or the service commissioners, who could require all clinics posting FP10MDA forms to use recorded in-person delivery and also put in place an administrative system to monitor for failed deliveries of prescription forms.”

Source location
Response from Boots UK
Page 2 · response
Published 10 March 2022
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
Pharmacies cannot detect failed deliveries because patients may choose any community pharmacy for dispensing.

Verbatim wording from the response
“Patients have a free choice regarding the community pharmacy that they attend for the dispensing of their prescriptions. It is therefore not possible for pharmacies to detect any failed deliveries.”

Source location
Response from Boots UK
Page 2 · response
Published 10 March 2022
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
Electronic transfer of controlled-drug instalment prescriptions is unavailable nationally, so physical prescriptions remain unavoidable until functionality is developed.

Verbatim wording from the response
“Unfortunately, the County Durham Drug and Alcohol Recovery Service, along with all other community drug and alcohol services, must rely on paper prescriptions as pharmacies cannot legally use faxed copies of prescriptions to dispense from for controlled drugs, including buprenorphine.”

Source location
Response from HumanKind
Page 1 · response
Published 10 March 2022
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
Electronic prescribing is unavailable for FP10MDA instalment prescriptions, leaving paper forms as the only legal mechanism.

Verbatim wording from the response
“The prescription in question for Ms Copeland was for methadone oral solution, a Schedule 2 Controlled Drug, the supply of which from a community pharmacy is governed by the Human Medicines Regulations 2012 and the Misuse of Drugs Regulations 2001 (as amended).”

Source location
Response from Boots UK
Page 1 · response
Published 10 March 2022
Open published response
21 May2021
Manchester City
Concerns raised1
1. Lack of patient alerts for requesting and collecting repeat prescriptions
Linked responses

EMIS Group
National Institute for Health and Care Excellence
Recipient name withheld
Respondent positions 4
1. EMIS Group
  The EMIS Web functionality was working as designed and complied with NHS Digital’s specified system requirements.
  Disputes the concern
1. National Institute for Health and Care Excellence
  Changes to the EMIS system cannot be influenced by NICE.
  Unable to act
2. National Institute for Health and Care Excellence
  NICE considers no action required because its implementation tools are put into practice locally.
  Redirects responsibility
3. Recipient name withheld
  The practice lacks sufficient administrative and clinical resources to respond appropriately to alerts about missed repeat prescriptions.
  Unable to act
AI-generated summary

Dyllon Shaun Graham Milburn · 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

Dyllon Shaun Graham Milburn died on 8 October 2019 in the garden of his home in Manchester from asphyxiation using a ligature made from a scarf. He had been prescribed Sertraline and had periods of non-compliance. The report raised concern that the repeat-prescription system did not allow automated alerts to remind patients to request and collect their medication.

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 patient alerts for requesting and collecting repeat prescriptions
Wider context from the report
“The system for repeat prescriptions does not currently allow for alerts to be sent to a patient to remind them to request and collect their repeat prescription to encourage compliance. ”
Source location
Dyllon Shaun Graham Milburn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The EMIS Web functionality was working as designed and complied with NHS Digital’s specified system requirements.

Verbatim wording from the response
“Firstly, we reviewed the functionality available within EMIS Web and confirmed that it was working as designed and in a manner that complies with the system requirements specified by NHS Digital.”

Source location
2021-0167-Response-from-EMIS_Published
Page 1 · response
Published 24 May 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Changes to the EMIS system cannot be influenced by NICE.

Verbatim wording from the response
“We have reflected on the circumstances surrounding Mr Milburn’s death, and the concerns raised in your report, in relation to NICE’s work. You suggest that an automated alert be added to the EMIS system to remind people to request and collect their repeat prescription to encourage compliance. While NICE is not able to influence changes to the EMIS system, the following NICE guidelines contain recommendations relevant to this report.”

Source location
2021-0167-Response-from-NICE_Published
Page 1 · response
Published 24 May 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NICE considers no action required because its implementation tools are put into practice locally.

Verbatim wording from the response
“NICE produces tools to support implementation of our recommendations, but they are put into practice locally. Therefore, we do not consider that any action is required by NICE in response to your report.”

Source location
2021-0167-Response-from-NICE_Published
Page 1 · response
Published 24 May 2021
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The practice lacks sufficient administrative and clinical resources to respond appropriately to alerts about missed repeat prescriptions.

Verbatim wording from the response
“There would also need to be a protocol in place to detail what an appropriate response would be when such an alert was triggered. Given that an alert would have to apply to all medications to all patients across the practice, there are concerns about the volume of alerts that may be triggered and that the practice does not have sufficient resources to provide an appropriate response to such alerts either in terms of administrative or clinician staffing or time.”

Source location
2021-0167-Response-from-GPs_Published
Page 2 · response
Published 24 May 2021
Open published response
24 Oct2017
West Sussex
Concerns raised1
1. Failure to establish and record arrangements for repeat prescription collection, delivery and pharmacy coordination
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Edward Jackson · 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 Edward Jackson, a 76-year-old man, fell at home and remained on the floor for about two weeks before he died on 17 July 2017. His death was recorded as accidental, with severe pressure sores associated with sepsis, toxaemia and rhabdomyolysis following prolonged immobility. Concerns included long-term repeat prescribing of Co-dydramol and Soneryl without regular face-to-face medical review, and unclear arrangements for prescription collection or 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
Failure to establish and record arrangements for repeat prescription collection, delivery and pharmacy coordination
Wider context from the report
“2. ████████ was also asked how were repeat prescriptions requested, collected or delivered. She was unable to help me in Mr Jackson's case but referred to a potential patient advocate, I believe meaning the person who nominated to collect his prescription. In this case for some time that was ████████ but given her increasing immobility this may have been a neighbour. ████████ also referred to working with local pharmacists but the details are unclear. This again suggests a need to review: a. the period of time that Mr Jackson remained on repeat prescriptions without being seen; b. the unknown arrangements for collection or delivery; and, c. possibly the arrangements with local pharmacies. ”
Source location
David Edward Jackson · Prevention of Future Deaths report
Page 2 · concerns
Open source report