Recipient

National Pharmacy Association

First report 12 Mar 2024•Latest report 2 Jun 2024

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Health-sector membership body. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
Published responses: 100%
Concerns addressed: 3
Stated actions: 4

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from National Pharmacy Association linked to the concerns in each report. Select any concern, action or position to view the source wording.

2 Jun2024
Berkshire
Concerns raised2
1. Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address
2. Lack of disseminated guidance for pharmacists issuing medication to patients with cognitive impairments
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review existing guidance and consider refinements for supporting patients with cognitive impairments.
  Stated planned
2. Action
  Consider ways to further raise awareness of cognitive-impairment medication safety among member pharmacies.
  Stated planned
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.

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 National Pharmacy Association; 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 National Pharmacy Association; 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
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 existing guidance and consider refinements for supporting patients with cognitive impairments.

Verbatim wording from the response
“The NPA supports its Member pharmacies with advice, guidance and resources to help them to provide person-centred care in accordance with the pharmacy regulator’s, the General Pharmaceutical Council’s, standards. Our support includes guidance on equality, diversity and inclusion, monitored dosage systems (dosette boxes) and reasonable adjustments, including guidance on conducting patient assessments to help pharmacies determine how best to support patients with different needs including visual impairment, confusion and dementia, and signposting to information and support from the General Pharmaceutical Council.”

Source location
Response from National Pharmacy Association
Page 1 · response
Published 15 October 2024
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
Consider ways to further raise awareness of cognitive-impairment medication safety among member pharmacies.

Verbatim wording from the response
“We will review our existing guidance and consider how we can refine it. We will consider how we can continue to further raise awareness of this issue with our Member pharmacies. In our role of Medication Safety Officer (MSO) for independent pharmacies, and a member of the sector-wide Patient Safety Group (which also includes representatives of corporate pharmacies), we will also raise this matter with the Group so that it can be considered by all MSOs across community pharmacy.”

Source location
Response from National Pharmacy Association
Page 1 · response
Published 15 October 2024
Open published response
12 Mar2024
Sunderland
Concerns raised1
1. Failure to prevent full-pack dispensing of Zuclopenthixol to patients prescribed weekly doses with suicidal risk and previous overdose attempts
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Raise concerns with the Department of Health and Social Care about clopixol pack sizes and special container status at forthcoming meetings.
  Stated planned
Respondent positions 2
1. Position
  Determining whether a particular medicine has special container status is outside the respondent’s influence and authority.
  Outside remit
1. Position
  The Department of Health and Social Care is ultimately responsible for the regulatory system and is the more appropriate body to address the matter.
  Redirects responsibility
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.

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 National Pharmacy Association; 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
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
Raise concerns with the Department of Health and Social Care about clopixol pack sizes and special container status at forthcoming meetings.

Verbatim wording from the response
“We will, however, raise concerns over Zuclopenthixol dihydrochloride (clopixol) coming in packs of ████████ and having a special container status at forthcoming meetings with the DHSC. You might consider that the DHSC is a more appropriate body to include in this Regulation 28 Report as they are ultimately responsible for the regulatory system.”

Source location
Response from National Pharmacy Association
Page 1 · response
Published 19 March 2024
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
Determining whether a particular medicine has special container status is outside the respondent’s influence and authority.

Verbatim wording from the response
“The NPA has no influence over determining if/whether a particular medicine has a special container status. We can only advise our member pharmacies to follow the special container status rules as set out by the Department of Health and Social Care (DHSC) in the Drug Tariff (Part II Clause 10), and Schedule 4 of the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013, which all pharmacy contractors are required to follow.”

Source location
Response from National Pharmacy Association
Page 1 · response
Published 19 March 2024
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 Department of Health and Social Care is ultimately responsible for the regulatory system and is the more appropriate body to address the matter.

Verbatim wording from the response
“We will, however, raise concerns over Zuclopenthixol dihydrochloride (clopixol) coming in packs of ████████ and having a special container status at forthcoming meetings with the DHSC. You might consider that the DHSC is a more appropriate body to include in this Regulation 28 Report as they are ultimately responsible for the regulatory system.”

Source location
Response from National Pharmacy Association
Page 1 · response
Published 19 March 2024
Open published response

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

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised2

Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address

Lack of disseminated guidance for pharmacists issuing medication to patients with cognitive impairments

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to prevent full-pack dispensing of Zuclopenthixol to patients prescribed weekly doses with suicidal risk and previous overdose attempts

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 2

Actions described in response 1

Respondent positions 2