Recipient

NHS Specialist Pharmacy Service

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First report 2 Jun 2024•Latest report 2 Jun 2024

Recipient record

Reports, concerns and published responses

Health and care · NHS provider group. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
4

Described in responses

Reports over time

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 NHS Specialist Pharmacy Service linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Berkshire

    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 NHS Specialist Pharmacy Service; 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 NHS Specialist Pharmacy Service; 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

    Advocate for Royal Pharmaceutical Society information and guidance to become available to non-members.

    Verbatim wording from the response

    “Suggested actions in response to the matters of concern”

    Source location

    Response from Specialist Pharmacy Service
    Page 3 · 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 adding wording recommending clear medicine labelling to distinguish household members, particularly those who are elderly or cognitively impaired.

    Verbatim wording from the response

    “13. The SPS will consider including additional wording to that in Annex 1, to recommend that medicines are clearly labelled for differentiation between household members, particularly for patients who are elderly and/or have cognitive impairment.”

    Source location

    Response from Specialist Pharmacy Service
    Page 3 · response
    Published 15 October 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

    Responsibility for labelling dispensed medicines lies with the regulator, so the service does not provide labelling information.

    Verbatim wording from the response

    “11. The labelling of dispensed medicines is within the remit of the regulator, the General Pharmaceutical Council, who has also been sent a copy of the Regulation 28 Report. The SPS does not provide information regarding the labelling of dispensed medicines.”

    Source location

    Response from Specialist Pharmacy Service
    Page 3 · response
    Published 15 October 2024

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
50%50%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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