Digital Health and Care Wales

Health and care · Special health authority

Request correction

First report 1 Oct 2025•Latest report 3 Feb 2026

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from Digital Health and Care Wales linked to the concerns in each report. Select any concern, action or position to view the source wording.

3 Feb2026
South Wales Central
Concerns raised3
1. Limited access for community pharmacists to patients’ drug histories and recent test results
2. Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person
3. Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Lyn Maher · 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

Lyn Maher, aged 79, was prescribed clarithromycin while taking simvastatin and was not advised to stop the statin. She was admitted to hospital, where the contraindicated co-ingestion was not identified, the statin continued, and rhabdomyolysis was missed; she died following cardiac arrest due to hyperkalaemia on 23 January 2024. The concerns included confusion among community pharmacists about clinical checks and confidentiality, and their limited access in Wales to relevant drug history and test results.

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 Digital Health and Care Wales; that does not assign responsibility.
PFD Monitor interpretation
Limited access for community pharmacists to patients’ drug histories and recent test results
Wider context from the report
“(3) I am concerned that community pharmacists in Wales only have very limited access to the Welsh Clinical Portal, where they can see relevant drug history and recent test results, which would enable them to properly and safely counsel patients to stop contraindicated drugs (here simvastatin with clarithromycin) but applicable more widely. I heard evidence that access to such information is available routinely in English pharmacies, but only in exceptional circumstances in Wales. I have no understanding of why this is the case. (4) Here, had either community pharmacist had access to Lyn’s drug history, they would have noted the contraindication and either told Lyn, her representative or written on the pharmacy bag that she was to stop the simvastatin. This likely would have changed the outcome for Lyn. ”
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 Digital Health and Care Wales; that does not assign responsibility.
PFD Monitor interpretation
Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person
Wider context from the report
“(2) I am concerned that there is confusion amongst community pharmacists in Wales around the conflict between the expectation of safe prescribing/dispensing and patient confidentiality (when someone other than the patient collects the medication). ”
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 Digital Health and Care Wales; that does not assign responsibility.
PFD Monitor interpretation
Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing
Wider context from the report
“(1) Evidence was heard that 2 separate community pharmacists did not tell Lyn, (nor pass a message via her family who collected the tablets), that she must stop taking simvastatin during the course of the clarithromycin, required for her chest infection. The pharmacists did not know she was taking simvastatin. I am concerned that there is confusion and a variety of opinion amongst community pharmacists around the extent of the expectation or duty to perform ‘clinical checks’ to enable safe prescribing and what that practically entails. ”
Open source report
1 Oct2025
South Wales Central
Concerns raised4
1. Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy
2. Failure to maintain follow-up of patients diagnosed with Barrett’s, including non-regular primary care attenders
3. Lack of recall or audit for patients with Barrett’s
1. Lack of prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Milos JANKOVIC · 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

Milos JANKOVIC had been diagnosed with Barrett’s Oesophagus in 2014 but was lost to follow-up surveillance after bowel cancer took priority. In 2020, he developed symptoms and was found to have brain metastases from primary oesophageal cancer. Concerns included inadequate processes for Barrett’s surveillance, particularly in primary care, and the absence of recall or prescribing prompts to identify patients needing surveillance or endoscopy.

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 Digital Health and Care Wales; that does not assign responsibility.
PFD Monitor interpretation
Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy
Wider context from the report
“(4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication, or whether they have previously been diagnosed with the condition and ought to be under surveillance. ”
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 Digital Health and Care Wales; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain follow-up of patients diagnosed with Barrett’s, including non-regular primary care attenders
Wider context from the report
“(1) There are two cases that have recently come to my attention within the Cardiff area where patients have been diagnosed with Barrett’s, lost to follow-up and have gone on to die from oesophageal cancers; (2) There are inadequate processes in place to address this lacuna, particularly in primary care where a patient may not be a regular attender; ”
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 Digital Health and Care Wales; that does not assign responsibility.
PFD Monitor interpretation
Lack of recall or audit for patients with Barrett’s
Wider context from the report
“(3) GPs frequently recall their patients with known, chronic issues such as asthma & diabetes, and there is a process for recalling women for smear tests for example, however Barrett’s does not currently benefit from such a recall exercise/audit, even though it is well-established to be a pre-cancerous condition; ”
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 Digital Health and Care Wales; that does not assign responsibility.
PFD Monitor interpretation
Lack of prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance
Wider context from the report
“(4) When prescribing drugs such as omeprazole or other PPIs for symptoms which may relate to Barrett’s, there is no prompt for GPs to consider whether the patient hits the relevant red flags which may benefit from endoscopy rather than a course of medication, or whether they have previously been diagnosed with the condition and ought to be under surveillance. ”
Open source report

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised3

Limited access for community pharmacists to patients’ drug histories and recent test results

Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person

Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing

Concerns raised4

Lack of prescribing prompts to assess Barrett’s-related red flags for endoscopy

Failure to maintain follow-up of patients diagnosed with Barrett’s, including non-regular primary care attenders

Lack of recall or audit for patients with Barrett’s

Lack of prescribing prompts to identify previously diagnosed Barrett’s patients requiring surveillance