3 Feb 2026 Lyn Maher · Prevention of Future Deaths report South Wales Central
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Concerns raised 3 Limited access for community pharmacists to patients’ drug histories and recent test results View source Confusion among community pharmacists about reconciling safe dispensing with patient confidentiality when medication is collected by another person View source Confusion and variation among community pharmacists about the duty to perform clinical checks for safe prescribing View source
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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.
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× 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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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
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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 Write to pharmacy owners, pharmacists and pharmacy technicians with patient-safety concerns, recommended safeguards and supporting resources.
Verbatim wording from the response “Raising awareness” Source location 2026-0053 - Response from General Pharmaceutical Council
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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 Digital Health and Care Wales is responsible for explaining pharmacy access requirements and planned changes to patient records in Wales.
Verbatim wording from the response “We note that you have shared your concerns with Digital Health and Care Wales who are well placed to explain their requirements for pharmacies in Wales providing NHS services to access patient records and any planned changes to access.” Source location 2026-0053 - Response from General Pharmaceutical Council
Open published response
31 Dec 2024 David Joseph Crompton · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 5 Failure to obtain and supply prescribed anti-epileptic medication promptly View source Lack of clear designated systems for dealing with medication supply shortages View source Failure to provide leaflets explaining roles during medication supply shortages View source Failure to learn lessons from potentially dangerous medication supply intervals View source Failure of pharmacies to search for supplies when prescribed medication is unavailable View source See 2 more concerns
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AI-generated summary
David Joseph Crompton · 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 Joseph Crompton, who had epilepsy, was left without his prescribed Tegretol for approximately 10 days in April 2024 and again in December 2024. His falls in both periods occurred when he was without the medication, and the inquest recorded a fall downstairs on 13 December 2024, with causes of death including hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest and cervical spine injury. The principal concerns were delays in supplying essential anti-epileptic medication, reliance on family members to seek alternative supplies, and the absence of clear systems for managing medication shortages.
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× 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and supply prescribed anti-epileptic medication promptly
Wider context from the report “(1) It is important that when anti-epileptic medication is prescribed by a GP that this is obtained and supplied promptly by the dispensing pharmacy . It is a matter of concern that for relatively lengthy periods on two occasions Mr Crompton was left without this important 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clear designated systems for dealing with medication supply shortages
Wider context from the report “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered ; for example, reference to hospital departments to ensure patients are not left without important medications . Leaflets explaining the role of those concerned in this situation were not provided.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide leaflets explaining roles during medication supply shortages
Wider context from the report “(4) Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered; for example, reference to hospital departments to ensure patients are not left without important medications. Leaflets explaining the role of those concerned in this situation were not provided .
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to learn lessons from potentially dangerous medication supply intervals
Wider context from the report “(3) The inquest was informed that following the April 2024 episode, hospital specialists commented that the absence of Tegretol for around 10 days “will likely have contributed to your seizure activity”. It is questionable whether lessons were learnt from this potentially dangerous interval .
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of pharmacies to search for supplies when prescribed medication is unavailable
Wider context from the report “(2) The evidence given by family members at the inquest was that when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies .
” 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 Publish guidance explaining how pharmacies should respond when prescribed medicines are unavailable.
Verbatim wording from the response “In November 2024 we published an article about medicines shortage, https://www.pharmacyregulation.org/about-us/news-and-updates/regulate/struggle-around-medicines-shortages The article states that if the pharmacy is unable to supply a particular medicine stated on prescription then they should talk to the patient to discuss their options. The article outlines examples of steps that pharmacy should take.” Source location Response from General Pharmaceutical Council
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 Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.
Verbatim wording from the response “The particular pharmacy has been inspected by our Inspection Team, who looked for evidence that the pharmacy was meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. The inspection included looking for evidence about the systems in place to manage medicines which were out of stock at the pharmacy and where there were supply issues at the wholesalers. This was to ensure practices in the pharmacy relating to stock management were appropriate.” Source location Response from General Pharmaceutical Council
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 Manufacturing medicines and wider supply and shortage issues fall outside the regulator’s direct role.
Verbatim wording from the response “We are aware of supply issues with some Tegretol products. While we do not have a direct role in the manufacturing of medicines or wider issues such as supply and shortages, we understand that medicines shortages can cause problems for patients and carers. We know that pharmacy professionals are also concerned and have to use their professional judgement and make decisions in challenging situations, balancing a range of factors such as individual patient needs and available supplies of medicines. Our standards require pharmacy professionals to deliver patient-centred care, which includes making the care of the patient their first concern and using their judgement to make professional decisions. This may include making decisions about providing medication in an emergency.” Source location Response from General Pharmaceutical Council
Open published response
20 Aug 2024 Hannah Enola Ayamo Jacobs · Prevention of Future Deaths report East London
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Concerns raised 5 Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom View source Insufficient education of parents and patients on safe AAI use when in doubt View source Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings View source Lack of sufficiently clear distinction between anaphylactic and mild reactions View source Unavailability of AAI stock in chemists for emergencies View source See 2 more concerns
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AI-generated summary
Hannah Enola Ayamo Jacobs · 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
Hannah Enola Ayamo Jacobs, aged 13, developed anaphylactic symptoms after being served a dairy hot chocolate despite her reported dairy allergy and later died following cardiac arrest. The concerns included dental staff not recognising excessive salivation as inability to swallow and a sign of anaphylaxis, possible misunderstanding of symptoms by her mother, and the availability and use of adrenaline auto-injectors during shortages.
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× 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Allergy plans failing to distinguish lip swelling as a potential anaphylaxis symptom
Wider context from the report “• The other symptom Hannah demonstrated was swelling of her lips which is listed on allergy plans as a mild to moderate symptom and thus provided a false sense of reassurance to her mother that cetirizine was what she needed.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient education of parents and patients on safe AAI use when in doubt
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction, and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT .
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise inability to swallow as a sign of anaphylaxis in dental settings
Wider context from the report “• The evidence at the inquest referred to allergy action plans discussed in the healthcare settings and given to parents and patients. Hannah displayed what appeared to be excessive salivation at the dentist which her paediatric consultant (who gave evidence) said, with the benefit of hindsight was actually a manifestation of her inability to swallow. This is a sign of anaphylaxis This was not recognised by dental staff as an inability to swallow and thus of anaphylaxis.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficiently clear distinction between anaphylactic and mild reactions
Wider context from the report “• The risk of future deaths in the context of anaphylaxis remains in the absence of further consideration of what constitutes an anaphylactic reaction as opposed to a mild reaction , and the education of parents and patients of the safety of using AAIs (adrenaline auto injectors) IF IN DOUBT.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of AAI stock in chemists for emergencies
Wider context from the report “• I was made aware there had been a shortage of AAI at the time but a vial of adrenaline was available at the chemist. However, it takes time to draw up. I am not sure if (assuming no national shortage) all chemists have AAI in stock for emergencies .
” Open source report
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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 Manufacturing medicines and addressing wider adrenaline autoinjector supply and shortage issues fall outside the regulatory role.
Verbatim wording from the response “We are aware of ongoing and intermittent supply issues with adrenaline autoinjectors (AAIs) which have been lasting for several years. While we do not have a direct role in the manufacturing of medicines or wider issues such as supply and shortages, we understand that medicines shortages can cause problems for patients, carers and those supporting people living with life-threatening allergies requiring adrenaline.” Source location Response from General Pharmaceutical Council
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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 The Department of Health and Social Care, manufacturers and wholesalers are best placed to answer specific medicine availability enquiries.
Verbatim wording from the response “Specific enquiries about the availability of particular medicines, can be directed to the medicines supply team at the Department of Health and Social Care (DHSC) on ████████. Alongside manufacturers and wholesalers, they would be best placed to help answer any questions you may have regarding the availability of medicines.” Source location Response from General Pharmaceutical Council
Open published response
Concerns raised 2 Failure to provide supervised doses of a controlled drug in accordance with the prescription's specified days and doses View source Failure to alert the drug treatment provider to dispensing outside the prescription View source
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
Anthony Paul Nixon · 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
Anthony Paul Nixon, aged 45, was found deceased at his home on 12 June 2023 after a drug overdose involving a combination of substances. The report identified concerns that a pharmacy supplied additional doses of a controlled drug in advance and contrary to the supervised-consumption prescription, leaving him in possession of multiple doses without notifying his drug treatment provider. The inquest concluded that the death was drug related and that the pharmacy’s actions contributed more than minimally by supplying the additional doses.
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× 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide supervised doses of a controlled drug in accordance with the prescription's specified days and doses
Wider context from the report “(1) The Pharmacist in this case gave evidence that he believed that he had a discretion to provide ████████ in advance, and not in accordance with the prescription for supervised provision of ████████ on specific days , and maintained this was a “standard practice” when the Pharmacy was open for half a day on Saturdays. He interpreted the wording on the prescription namely “please dispense instalments due on a Pharmacy closed days on a prior suitable date” to include Saturdays when the Pharmacy was open for half a day, despite the prescriptions stipulating the specific days that the ████████ was to be provided, including specification of the dose each Saturday .
(2) This led to a situation where the deceased was in possession of multiple doses of a controlled drug, namely ████████, on a regular basis in the period leading up to his death, which was not in accordance with the prescription , which had been carefully considered to attempt to manage the obvious risks of such.
(3) The Pharmacy had been specifically chosen by the deceased’s drug treatment provider because it was able to provide supervised administration of ████████ on a 6 day per week basis and because in their assessment this was required to attempt to manage the risks inherent in the deceased having access to multiple doses.
(4) The treatment provider were not alerted to the fact that the deceased was regularly receiving additional doses of ████████ not in accordance with the prescription they had issued, and so was unable to risk manage the suitability of the prescribing arrangements.
(5) I was not reassured that the Pharmacist fully appreciates the gravity of this situation, and that in evidence he continued to maintain that he could exercise a discretion in relation to the provision of ████████, a controlled drug, and provide this not in accordance with specific prescription instructions on the days specified when the Pharmacy was open, and further that was described as a standard practice.
(6) For the avoidance of doubt, the circumstances of this case have been alerted to the General Pharmaceutical Council, as the appropriate regulator, but there has been no update received as to whether an investigation has been undertaken or any action recommended.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to alert the drug treatment provider to dispensing outside the prescription
Wider context from the report “(1) The Pharmacist in this case gave evidence that he believed that he had a discretion to provide ████████ in advance, and not in accordance with the prescription for supervised provision of ████████ on specific days, and maintained this was a “standard practice” when the Pharmacy was open for half a day on Saturdays. He interpreted the wording on the prescription namely “please dispense instalments due on a Pharmacy closed days on a prior suitable date” to include Saturdays when the Pharmacy was open for half a day, despite the prescriptions stipulating the specific days that the ████████ was to be provided, including specification of the dose each Saturday.
(2) This led to a situation where the deceased was in possession of multiple doses of a controlled drug, namely ████████, on a regular basis in the period leading up to his death, which was not in accordance with the prescription, which had been carefully considered to attempt to manage the obvious risks of such.
(3) The Pharmacy had been specifically chosen by the deceased’s drug treatment provider because it was able to provide supervised administration of ████████ on a 6 day per week basis and because in their assessment this was required to attempt to manage the risks inherent in the deceased having access to multiple doses.
(4) The treatment provider were not alerted to the fact that the deceased was regularly receiving additional doses of ████████ not in accordance with the prescription they had issued , and so was unable to risk manage the suitability of the prescribing arrangements .
(5) I was not reassured that the Pharmacist fully appreciates the gravity of this situation, and that in evidence he continued to maintain that he could exercise a discretion in relation to the provision of ████████, a controlled drug, and provide this not in accordance with specific prescription instructions on the days specified when the Pharmacy was open, and further that was described as a standard practice.
(6) For the avoidance of doubt, the circumstances of this case have been alerted to the General Pharmaceutical Council, as the appropriate regulator, but there has been no update received as to whether an investigation has been undertaken or any action recommended.
” 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 Inspect the pharmacy’s governance and methadone dispensing arrangements against the Standards for Registered Pharmacies.
Verbatim wording from the response “As part of this, the pharmacy has recently been inspected by one of our inspectors, who looked for evidence that the pharmacy is meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. The inspection included looking for evidence about the governance arrangements and the way the service for people taking methadone was being delivered. This was to ensure practices in the pharmacy, including supply of daily doses of methadone on days prior to the pharmacy being closed met the requirements of the prescriptions being dispensed. The Inspection report will be published in due course, showing some minor non-compliance and advice being given. Evidence collected during the visit to the pharmacy has been shared with our FtP colleagues.” Source location Response from General Pharmaceutical Council
Open published response
2 Jun 2024 Sewa Kaur Chaddha · Prevention of Future Deaths report Berkshire
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Concerns raised 2 Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address View source Lack of disseminated guidance for pharmacists issuing medication to patients with cognitive impairments View source
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
Sewa Kaur Chaddha · 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
Sewa Kaur Chaddha was found collapsed at home after taking her husband’s medication instead of her own for several days, including diabetes medication. She died in hospital from hyponatraemia caused by treatment for hypoglycaemia resulting from the accidental ingestion of hypoglycaemic medication. Concerns included the identical appearance of the couple’s dosset boxes, small patient-name labels, and the absence or poor dissemination of guidance for pharmacists supplying medication to people with cognitive impairment.
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× 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address
Wider context from the report “1) The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis.
(2) Both patients were elderly and had cognitive impairment.
(3) The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name.
(4) Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days.
(5) Evidence was given at the inquest that there was no guidance or policy in place for Pharmacists to follow when issuing medication to patients with cognitive impairments, or if there was, it was not well disseminated among the pharmacist population.
(6) Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of disseminated guidance for pharmacists issuing medication to patients with cognitive impairments
Wider context from the report “1) The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis.
(2) Both patients were elderly and had cognitive impairment.
(3) The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name.
(4) Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days.
(5) Evidence was given at the inquest that there was no guidance or policy in place for Pharmacists to follow when issuing medication to patients with cognitive impairments , or if there was, it was not well disseminated among the pharmacist population.
(6) Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address.
” 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 Publish information for pharmacy professionals on supporting patients with dementia and their carers when supplying and managing medicines.
Verbatim wording from the response “care that takes account of the diverse needs and cultural differences in the communities they serve. To share an example, we recently published information to the pharmacy profession about providing services to patients and their carers living with dementia, as an umbrella term for a range of over 200 subtypes of progressive conditions that affect the brain and a person’s ability to remember, think and speak. Through this communication, we highlighted the following points about supporting patients who may need assistance with their medicines:” Source location Response from General Pharmaceutical Council
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Produce supporting equality guidance to help pharmacy owners and professionals provide person-centred care for patients with different needs, including cognitive impairment.
Verbatim wording from the response “We also produce supporting guidance to help pharmacy owners and pharmacy professionals to put the standards into practice. This includes our equality guidance, which is designed to help pharmacy owners improve the experience and healthcare outcomes of patients and members of the public using their pharmacy’s services. The guidance sets out examples taken from our GPhC Knowledge Hub and our pharmacy inspections work about how pharmacy teams are supporting patients with different needs, including cognitive and visual impairment.” Source location Response from General Pharmaceutical Council
Open published response
12 Mar 2024 Jason Brown · Prevention of Future Deaths report Sunderland
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Concerns raised 1 Failure to prevent full-pack dispensing of Zuclopenthixol to patients prescribed weekly doses with suicidal risk and previous overdose attempts View source
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AI-generated summary
Jason Brown · 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
Jason Brown died at his home on 6 September 2022 after taking an overdose of his prescribed medication; the inquest concluded suicide, with the medical cause recorded as cardiac arrhythmia and drug overdose. The report raises concern that original-pack dispensing requirements for Zuclopenthixol dihydrochloride could provide a patient with suicidal risk and previous overdose attempts with a large quantity of medication.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent full-pack dispensing of Zuclopenthixol to patients prescribed weekly doses with suicidal risk and previous overdose attempts
Wider context from the report “At the Inquest I heard evidence that prior to his death on 6th September 2022, Jason Brown received from the pharmacy his prescribed medication in a form of a full pack of ████████ tablets of Zuclopenthixol dihydrochloride (clopixol). The pharmacy confirmed in evidence that this had been dispensed as a full pack in accordance with its special container status. Jason was prescribed his medication in weekly doses due to a history which included previous attempts to take an overdose of his medication. Jason received this full pack of tablets only 17 days before taking an overdose of this medication on 6th September 2022. The pharmacy also confirmed that another patient at the practice received the same medication in a 7-day monitored dosage system (MDS) but could not confirm whether the remaining pack was then disposed of for that patient.
I am concerned that, due to a special container status, a box of ████████ tablets of Zuclopenthixol dihydrochloride (clopixol) must be dispensed in its own special container as a full pack of ████████ tablets (original pack dispensing) and that this can endanger the safety of a patient with a history of suicidal risk and previous overdose attempts.
Deaths may be prevented if the original pack dispensing guidance was reviewed for this medication.
” 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 Consider communications to raise pharmacy-profession awareness of special-container quantity exceptions.
Verbatim wording from the response “Going forward, we will consider whether there are any communications we can issue to the pharmacy professions to raise awareness, including about the exceptions to the rules around quantity to supply for special containers.” Source location Response from General Pharmaceutical Council
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 Licensing, medicine status and pack size fall outside the respondent’s direct regulatory role.
Verbatim wording from the response “The General Pharmaceutical Council (GPhC) has a statutory purpose to protect patients by setting and upholding the standards for registered pharmacies and the standards for pharmacy professionals, to ensure that registered pharmacies are safe to provide services, and that pharmacy professionals are fit to practise. We do not have a direct role in relation to the licensing, status or pack size of medicines. These would be matters for the Medicines and Healthcare Products Regulatory Agency (MHRA), the Department of Health and Social Care and the medicines manufacturer. However, we do have a role in supporting professionals to meet our standards and to dispense safely, taking account of relevant national policy and guidelines.” Source location Response from General Pharmaceutical Council
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 The MHRA, Department of Health and Social Care, and manufacturer are responsible for medicine licensing, status and pack size.
Verbatim wording from the response “The General Pharmaceutical Council (GPhC) has a statutory purpose to protect patients by setting and upholding the standards for registered pharmacies and the standards for pharmacy professionals, to ensure that registered pharmacies are safe to provide services, and that pharmacy professionals are fit to practise. We do not have a direct role in relation to the licensing, status or pack size of medicines. These would be matters for the Medicines and Healthcare Products Regulatory Agency (MHRA), the Department of Health and Social Care and the medicines manufacturer. However, we do have a role in supporting professionals to meet our standards and to dispense safely, taking account of relevant national policy and guidelines.” Source location Response from General Pharmaceutical Council
Open published response
10 Jul 2023 Harold Wilberforce · Prevention of Future Deaths report East Riding and Hull
View report summary
Concerns raised 2 Lack of clarity about roles, responsibilities and required actions during falls at elderly service users' homes View source Lack of training for pharmacy delivery staff on responding to service-user falls at home View source
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
Harold Wilberforce · 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
Harold Wilberforce fell at home on 16 January 2023, sustained a broken hip and was taken to hospital, where he contracted bronchopneumonia and died on 28 January 2023. Concerns included the lack of medical examination after the fall, the pharmacy delivery agent’s lack of awareness of his dementia, the absence of relevant staff training, and unclear roles and responsibilities when elderly service users are found to have fallen.
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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about roles, responsibilities and required actions during falls at elderly service users' homes
Wider context from the report “(3) I am concerned that a lack of clarity exists in respect of the roles and responsibilities of persons attending upon the home addresses of elderly service users , particularly in the context of what action should be taken when someone is found to have fallen .
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of training for pharmacy delivery staff on responding to service-user falls at home
Wider context from the report “(2) Evidence was provided on behalf of the pharmacy that there was no training provided to staff members in respect of how to deal with and what actions should be taken when a service user is found to have had a fall at their home address by a pharmacy delivery agent . Evidence was also heard that the majority of service users were elderly persons.
” 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 Set training requirements for unregistered pharmacy staff, including delivery drivers.
Verbatim wording from the response “Delivery drivers themselves are not registered or directly regulated by us; nevertheless we have published guidance to ensure a safe and effective pharmacy team and we set requirements for the training of unregistered staff (which includes delivery drivers).” Source location Response from General Pharmaceutical Council
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 inspectors to discuss pharmacy procedures for responding when delivery agents find service users fallen or otherwise at risk.
Verbatim wording from the response “We will also remind our inspectors to make sure that they include, through our ongoing inspections, discussions about whether a pharmacy has SOPs in place to support delivery agents/drivers and wider teams to know what to do and who to contact if they find that a service user has had a fall or is at risk in other ways. The inspectors do currently routinely ask about how pharmacies ensure that children and vulnerable adults are safeguarded. This means that we can check if pharmacies are proactively considering how to manage the risks associated with these situations.” Source location Response from General Pharmaceutical Council
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 Assess the pharmacy’s safeguarding risks and factor the concern into inspection timing and focus decisions.
Verbatim wording from the response “From what has been described to us, on this occasion it does appear that there has been a failure to safeguard a vulnerable service-user. As the issues you have raised fall more into the category of how the pharmacy is being operated, we have referred the matter to our local Inspector who covers this particular pharmacy. They will assess the risks posed by the issues you have described, and determine what follow-up action may be appropriate. The Inspector will also factor this information into their decision-making” Source location Response from General Pharmaceutical Council
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 regulator does not mandate training details for particular scenarios because pharmacy support staff have diverse roles.
Verbatim wording from the response “Pharmacy owners are also accountable for making sure their unregistered staff meet our requirements for training. The scope of work of pharmacy support staff is hugely diverse, so we do not mandate specific detail about particular scenarios. We specify a set of learning outcomes which all support staff must achieve. These include outcomes relating to:” Source location Response from General Pharmaceutical Council
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 Pharmacy owners are responsible for ensuring unregistered staff receive appropriate training.
Verbatim wording from the response “Our guidance states that pharmacy owners are responsible for making sure that the whole pharmacy team – both registered pharmacy professionals and all unregistered staff – provide safe and effective care and pharmacy services. Staff members, and anyone involved in providing pharmacy services, must be competent and empowered to safeguard the health, safety and wellbeing of patients and the public in all that they do.” Source location Response from General Pharmaceutical Council
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 Delivery drivers are not directly regulated by the regulator.
Verbatim wording from the response “Delivery drivers themselves are not registered or directly regulated by us; nevertheless we have published guidance to ensure a safe and effective pharmacy team and we set requirements for the training of unregistered staff (which includes delivery drivers).” Source location Response from General Pharmaceutical Council
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 regulator’s role covers registered pharmacists and pharmacy technicians, not unregistered delivery drivers.
Verbatim wording from the response “In addition, not all those who work within a pharmacy company, such as delivery drivers, are required to be registered professionals, and our role only covers individuals who are registered pharmacists or pharmacy technicians.” Source location Response from General Pharmaceutical Council
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 Delivery drivers are not generally expected to receive training specifically for managing a service-user’s fall at home or to enter patients’ homes.
Verbatim wording from the response “This matter relates to pharmacy support staff. The roles and responsibilities of pharmacy support staff, such as delivery drivers, will be defined by the pharmacy. They, however, must be suitably qualified for the roles that they do. GPhC requirements for the education and training of pharmacy support staff includes being able to recognise and raise appropriate safeguarding concerns, particularly involving vulnerable adults. However, delivery drivers would not be expected to receive training specifically with how to manage a situation where a service-user has had a fall at home, and would also not normally enter patient’s homes.” Source location Response from General Pharmaceutical Council
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 pharmacy defines support staff roles, while its Superintendent pharmacist is responsible for ensuring their training and competencies meet requirements.
Verbatim wording from the response “This matter relates to pharmacy support staff. The roles and responsibilities of pharmacy support staff, such as delivery drivers, will be defined by the pharmacy. They, however, must be suitably qualified for the roles that they do. GPhC requirements for the education and training of pharmacy support staff includes being able to recognise and raise appropriate safeguarding concerns, particularly involving vulnerable adults. However, delivery drivers would not be expected to receive training specifically with how to manage a situation where a service-user has had a fall at home, and would also not normally enter patient’s homes.” Source location Response from General Pharmaceutical Council
Open published response
Concerns raised 8 Failure to protect questionnaire answers from alteration View source Failure to flag refusal to share prescribing information for further enquiry View source Lack of central tracking of prescribed and dispensed drugs View source Lack of required face-to-face consultation before dispensing drugs View source Inadequate questionnaire on the person's medical history View source Failure to notify the person's GP of prescribed drugs View source Limited regulation of the prescribing company View source Failure to prevent drug selection before prescriber contact View source See 5 more concerns
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
Jamie Francis O'Connor · 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
Jamie O’Connor was found deceased in the garden of his home in Leicester on 14 October 2018 after his mother became concerned that he was not responding to phone calls. The report identified concerns about online prescribing, including the lack of central tracking, limited information sharing with GPs, no required face-to-face consultation, limited questionnaires, patients requesting specific drugs, and limited regulation; the inquest concluded that this was a drug-related death and recorded the cause as ████████ toxicity.
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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to protect questionnaire answers from alteration
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed ;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to flag refusal to share prescribing information for further enquiry
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of central tracking of prescribed and dispensed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of required face-to-face consultation before dispensing drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed ;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate questionnaire on the person's medical history
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the person's GP of prescribed drugs
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Limited regulation of the prescribing company
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent drug selection before prescriber contact
Wider context from the report “1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs.
2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP.
3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;
4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed;
5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber ;
6. By virtue of where the company prescribing the drugs was registered there was limited regulation.
” 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 Publish guidance for pharmacist prescribers on sharing prescribing information with people’s prescribers and other care professionals.
Verbatim wording from the response “We have also published ‘In practice: Guidance for pharmacist prescribers’, which set out the key areas we expect pharmacist prescribers to consider when applying the standards to their prescribing practice. The guidance states that prescribing information should be shared with the person’s prescriber, or others involved in their care, so the person receives safe and effective care.” Source location 2021-0363-Response-from-GPC_Published
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 Enforce pharmacy standards by taking action against unsafe online medicine supply, including improvement notices and registration conditions.
Verbatim wording from the response “We have taken enforcement action against the owners of online pharmacies who are supplying high risk, habit-forming medicines without appropriate steps being taken to check that the medicine being prescribed and dispensed is clinically appropriate for the patient.” Source location 2021-0363-Response-from-GPC_Published
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 Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.
Verbatim wording from the response “We have also worked with other healthcare organisations including regulators, royal colleges and faculties and have jointly-agreed High level principles for good practice in remote consultations and prescribing that set out the good practice of healthcare professionals when prescribing medication online. The ten principles, underpinned by existing expected standards and guidance, include that healthcare professionals are expected to:” Source location 2021-0363-Response-from-GPC_Published
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 central system or database tracking prescribed and dispensed medicines, and the responsible individuals, is outside the remit.
Verbatim wording from the response “We acknowledge your concern that there is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom. Although this specific aspect is outside of our remit, we do produce guidance, which is designed to support pharmacy owners and pharmacy professionals to meet our standards.” Source location 2021-0363-Response-from-GPC_Published
Open published response
Concerns raised 2 Lack of national guidance or standards for sharing medication risk information and care plans with local pharmacies View source Failure to ensure appropriate pharmacy involvement in medication safety plans for mental health patients aged 16–17 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
SAMANTHA JANE GOULD (Sam) · 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
Sam took a very large quantity of prescribed medication at home in the early hours of 2 September 2018 and died within at most a couple of hours. The local pharmacy had not been told about a safety plan under which Sam’s parents were responsible for her medication. The report identified a concern that, without national action to ensure pharmacies are involved in medication safety plans for mental health patients aged 16–17, similar fatalities could occur.
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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance or standards for sharing medication risk information and care plans with local pharmacies
Wider context from the report “(1) There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
(2) A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
However,
(3) I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16 – 17, given that such patients may otherwise be able to obtain prescribed medication with which to overdose.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate pharmacy involvement in medication safety plans for mental health patients aged 16–17
Wider context from the report “(1) There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
(2) A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
However,
(3) I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16 – 17 , given that such patients may otherwise be able to obtain prescribed medication with which to overdose .
” 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 NHS England is better placed to provide information on national-level medication safety plans.
Verbatim wording from the response “Also, I note that your report has been sent to NHS England. Whilst we produce guidance and advice of our standards, NHS England may be better placed to provide you information on medication safety plans at a national level.” Source location 2021-0186-Response-from-GPC_Published
Open published response
7 Dec 2019 Matthew Colin FITTEN · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 2 Failure to provide measuring equipment and instructions for accurate daily methadone dosing View source Failure to dispense prescribed methadone in single daily dosage bottles View source
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.
×
AI-generated summary
Matthew Colin FITTEN · 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
Matthew Fitten was found deceased at home on 17 April 2020, and toxicology identified a toxic quantity of methadone in his blood. During the COVID-19 pandemic, his methadone collection was changed from three times per week to fortnightly, but he received three large bottles without a measuring jug or instructions for accurately measuring his prescribed daily dose. The report identifies concerns that this increased access to methadone and the lack of suitable dosing arrangements contributed to his death.
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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide measuring equipment and instructions for accurate daily methadone dosing
Wider context from the report “During the evidence it was heard that at the start of the Covid19 pandemic PHE guidance was issued to Turning Point (the Suffolk Recovery Network) that individuals on opiate replacement treatment (Methadone) should be moved off short term (daily or tri-weekly) prescription collections to longer term ones.
In Matthew’s case his collection was changed from 3 times per week to fortnightly.
The doctor who made the changes to the prescription stipulated that Matthew’s dose must be in single daily dosage bottles. Matthew had a secure store in his home and was used to taking his Methadone from single daily dosage bottles.
In addition the Turning Point doctor had sent a letter to all of the pharmacy’s that supplied opiate replacement therapies to his patients, explaining that only daily usage bottles should be prescribed.
On the 15th April 2020 Matthew collected his 14-day methadone supply from the Haverhill Pharmacy in Haverhill, Suffolk.
Evidence produced by Matthews father during the inquest itself, clearly showed that Matthew had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of Methadone respectively.
In addition, because Matthew’s prescription had been for single dose bottles a separate ‘measuring jug’ had not been prescribed by the Turning Point doctor.
Matthew’s prescribed dose of Methadone was 54ml daily. As such, when Matthew was given the 100ml, 156ml and 500ml Methadone bottles on the 15th April 2020, he was not given anything to accurately measure his daily dose from them.
It is therefore probable, that due to a lack of a measuring jug, Matthew guessed his first dose from the larger Methadone bottles with tragic consequences.
Had Matthew been given daily dose bottles of Methadone as prescribed, or a measuring jug and instructions on how to use it had been provided , on a balance of probability basis his death would not have occurred.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to dispense prescribed methadone in single daily dosage bottles
Wider context from the report “During the evidence it was heard that at the start of the Covid19 pandemic PHE guidance was issued to Turning Point (the Suffolk Recovery Network) that individuals on opiate replacement treatment (Methadone) should be moved off short term (daily or tri-weekly) prescription collections to longer term ones.
In Matthew’s case his collection was changed from 3 times per week to fortnightly.
The doctor who made the changes to the prescription stipulated that Matthew’s dose must be in single daily dosage bottles. Matthew had a secure store in his home and was used to taking his Methadone from single daily dosage bottles.
In addition the Turning Point doctor had sent a letter to all of the pharmacy’s that supplied opiate replacement therapies to his patients, explaining that only daily usage bottles should be prescribed.
On the 15th April 2020 Matthew collected his 14-day methadone supply from the Haverhill Pharmacy in Haverhill, Suffolk.
Evidence produced by Matthews father during the inquest itself, clearly showed that Matthew had been issued three bottles of Methadone to cover the 14-day period. These bottles contained 100ml, 156ml and 500ml of Methadone respectively.
In addition, because Matthew’s prescription had been for single dose bottles a separate ‘measuring jug’ had not been prescribed by the Turning Point doctor.
Matthew’s prescribed dose of Methadone was 54ml daily. As such, when Matthew was given the 100ml, 156ml and 500ml Methadone bottles on the 15th April 2020, he was not given anything to accurately measure his daily dose from them.
It is therefore probable, that due to a lack of a measuring jug, Matthew guessed his first dose from the larger Methadone bottles with tragic consequences.
Had Matthew been given daily dose bottles of Methadone as prescribed , or a measuring jug and instructions on how to use it had been provided, on a balance of probability basis his death would not have occurred.
” Open source report
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.
×
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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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 General Pharmaceutical Council; 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
24 Oct 2018 Jennifer Anne Lacey · Prevention of Future Deaths report Inner West London
View report summary
Concerns raised 4 Unrestricted internet availability of potentially dangerous and addictive drugs View source Failure to perform further checks when filling prescriptions for potentially dangerous and addictive drugs in UK pharmacies View source Failure to access the patient’s medical records before prescribing potentially dangerous and addictive drugs View source Failure to contact the patient’s regular medical practitioner before prescribing potentially dangerous and addictive drugs View source See 1 more concern
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
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. The report was sent to General Pharmaceutical Council; that does not assign responsibility.
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.
” 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 General Pharmaceutical Council; that does not assign responsibility.
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 .
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to access the patient’s medical records before prescribing 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.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure to contact the patient’s regular medical practitioner before prescribing 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.
” Open source report
13 Oct 2017 Ms Christina Ann Fletcher · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 2 Lack of specific regulatory guidance on pharmacy red-flag systems for patients with potentially confusing identities or addresses View source Lack of specific guidance defining when, where and how the chain of custody for controlled drugs is completed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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. The report was sent to General Pharmaceutical Council; that does not assign responsibility.
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.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of specific guidance defining when, where and how the chain of custody for controlled drugs is completed
Wider context from the report “2. Again, there is no specific guidance, policy or protocol from the Regulator (or indeed legal definition) as to when, where and how the chain of custody (for Controlled Drugs) is completed. It currently appears to be a matter of local practice with some Pharmacies make an entry into the CD Register at the point the CD is handed to the delivery driver, with others making an entry once delivery has been confirmed.
” 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 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
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 The Home Office is best placed to provide information about controlled drug legislation and chain of custody.
Verbatim wording from the response “Whilst we produce guidance and advice of our standards, we do not produce detailed advice on the law. However, the Royal Pharmaceutical Society (RPS) (www.rpharms.com) is the professional body for pharmacists in Great Britain and has produced guidance on the delivery and posting (including abroad) of medicines to patients and maintains practice guidance on the management of controlled drugs. For further information about the chain of custody for Controlled Drugs the Home Office, as the body responsible for controlled drug legislation, is best placed to provide you with this information.” Source location Christina-Fletcher_Redacted
Open published response
9 Jan 2015 Annette Charlton · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Almost identical medication boxes View source
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.
×
AI-generated summary
Annette Charlton · 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
Annette Charlton, who had emphysema and lung fibrosis requiring continuous oxygen therapy, was dispensed Naproxen instead of prescribed antibiotics and died on 28 September 2014. The principal concern was that medication manufacturers used almost identical packaging, which was considered likely to contribute to dispensing errors and potentially patient deaths.
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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Almost identical medication boxes
Wider context from the report “(1) Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.
” Open source report
27 Jan 2014 Judith Lesley Marshall · Prevention of Future Deaths report York City
View report summary
Concerns raised 7 Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors View source Absence of a central database of prescription errors View source Failure of colleague checking to prevent dispensing medication errors View source Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions View source Lack of policing of internal pharmacy error records View source Lack of mandatory read-back procedures for dispensing details View source Lack of central monitoring and trend analysis of prescription errors View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Judith Lesley Marshall · 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
Judith Lesley Marshall was prescribed morphine sulphate 10mg twice daily, but a pharmacy dispensed 60mg capsules. She took the capsules as prescribed and was found dead on 30 September 2009; the inquest recorded bronchopneumonia and the effects of morphine, with a conclusion of accidental death. The principal concerns were pharmacy dispensing errors, the adequacy of checking and monitoring systems, and the absence of central monitoring of prescription errors.
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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
Wider context from the report “(3) It is not clear whether there is any software , obtainable from the Department of Health or elsewhere, that could read prescriptions and raise an alert if the label sought to be created or if the drug sought to be dispensed is wrong in identity or amount . This would be of particular significance when a high risk drug is dispensed or when a drug is dispensed in an unusual quantity, dosage or form.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Absence of a central database of prescription errors
Wider context from the report “(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Failure of colleague checking to prevent dispensing medication errors
Wider context from the report “(2) Despite a system of checking by a colleague it is apparent that there can be a mistake in dispensing medication which in this case was a controlled opiate drug. The consequences were fatal.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions
Wider context from the report “(5) A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of policing of internal pharmacy error records
Wider context from the report “(1) The Pharmacy’s Errors Book shows a number of drug errors (including higher or lower dose tablets and three wrong drugs) over a number of years. It is not clear whether and to what extent such internal records are policed .
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory read-back procedures for dispensing details
Wider context from the report “(4) Mandatory procedures requiring a ‘read-back’ of the drug, its dosage, its frequency of administration and its total quantity may prevent such dispensing errors . In so far as the error in this case can be attributable to ‘Human Error’ it is concluded that the dispensing pharmacist focused on the figure of 60 and incorrectly attributed that to the dosage as well as to the number of capsules.
” 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 General Pharmaceutical Council; that does not assign responsibility.
PFD Monitor interpretation Lack of central monitoring and trend analysis of prescription errors
Wider context from the report “(6) There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors .
” 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 Highlight existing dispensing-error guidance, including involving two people where possible, in the next Regulate+ newsletter.
Verbatim wording from the response “2. The GPhC has published guidance which contains information about minimising the risk of dispensing errors (http://www.pharmacyregulation.org/sites/default/files/Responding%20to%20complaints%20and%20%20concerns%20.pdf). The guidance explains that two people should be involved in the dispensing process where this is possible. Whilst I understand that in this case, two people were involved in the dispensing process, we can highlight our guidance in the next edition of our newsletter through Regulate+.” Source location 2014-0039-Response-by-General-Pharmaceutical-Council
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 Review whether pharmacy inspections should interrogate recorded dispensing errors more extensively.
Verbatim wording from the response “1. We set standards for registered pharmacies which focus on the outcomes we expect to see in registered pharmacies. We inspect registered pharmacies against the standards and produce reports of our findings.” Source location 2014-0039-Response-by-General-Pharmaceutical-Council
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 working with MHRA and NHS England to ensure pharmacy professionals use the National Reporting and Learning System.
Verbatim wording from the response “6. The medicines regulator, the MHRA, has been working with NHS England to develop draft Patient Safety Alerts and guidance to increase adverse incident reporting via the National Reporting and Learning System (NRLS), which is a central database of patient safety incident reports. We continue to work with the MHRA and NHS England to ensuring that pharmacists and pharmacy technicians use the NRLS.” Source location 2014-0039-Response-by-General-Pharmaceutical-Council
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 The regulator cannot require registered pharmacies to use automation to reduce dispensing errors.
Verbatim wording from the response “3. There is research that shows the use of automation within a dispensing process can reduce the rate of errors. Whilst we cannot require registered pharmacies to use automation, we do ensure that the way in which we regulate does not stifle the introduction of new technology.” Source location 2014-0039-Response-by-General-Pharmaceutical-Council
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations