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
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
Action
Advocate for Royal Pharmaceutical Society information and guidance to become available to non-members.
View source
Action
Consider adding wording recommending clear medicine labelling to distinguish household members, particularly those who are elderly or cognitively impaired.
View source
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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 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
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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 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
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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 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
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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations