Concerns raised 4 Lack of a mechanism to remedy failed delivery View source Lack of an effective mechanism for immediate detection of failed delivery View source Failure to witness or confirm delivery View source Reliance upon delivery of a physical prescription document View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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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. The report was sent to Boots UK Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
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.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation 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
Open published response
4 Oct 2019 Michael Lobban · Prevention of Future Deaths report London Inner (West)
View report summary
Concerns raised 7 Delays in investigating controlled-drug discrepancies View source Failure to fully follow through contact with regular methadone prescription users View source Lack of sanctions for pharmacies mislaying controlled drugs View source Lack of regulatory investigative powers for controlled-drug discrepancies View source Lack of physical checking of prescription-box contents during controlled-drug audits View source Lack of double-checking in controlled-drug audits View source Lack of pharmacy reporting requirements for schedule 2 controlled-drug discrepancies View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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. The report was sent to Boots UK Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in investigating controlled-drug discrepancies
Wider context from the report “1. The investigation carried out by The Boots Company PLC into the disparity of Methadone tablets on this occasion was slow and efforts to contact patients who were regular prescription users of methadone was not fully followed through.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to fully follow through contact with regular methadone prescription users
Wider context from the report “1. The investigation carried out by The Boots Company PLC into the disparity of Methadone tablets on this occasion was slow and efforts to contact patients who were regular prescription users of methadone was not fully followed through .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of regulatory investigative powers for controlled-drug discrepancies
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of double-checking in controlled-drug audits
Wider context from the report “2. The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Boots UK Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of pharmacy reporting requirements for schedule 2 controlled-drug discrepancies
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.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations