Recipient

Royal Pharmaceutical Society of Great Britain

First report 27 Jan 2014•Latest report 27 Jan 2014

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Royal Pharmaceutical Society of Great Britain linked to the concerns in each report. Select any concern, action or position to view the source wording.

27 Jan2014
York City
Concerns raised7
1. Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors
2. Absence of a central database of prescription errors
3. Failure of colleague checking to prevent dispensing medication errors
1. Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions
2. Lack of policing of internal pharmacy error records
3. Lack of mandatory read-back procedures for dispensing details
4. Lack of central monitoring and trend analysis of prescription errors
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

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 Royal Pharmaceutical Society of Great Britain; 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 Royal Pharmaceutical Society of Great Britain; 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 Royal Pharmaceutical Society of Great Britain; 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 Royal Pharmaceutical Society of Great Britain; 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 Royal Pharmaceutical Society of Great Britain; 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 Royal Pharmaceutical Society of Great Britain; 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 Royal Pharmaceutical Society of Great Britain; 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

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 raised7

Uncertainty about availability of prescription-reading software alerts for drug identity or amount errors

Absence of a central database of prescription errors

Failure of colleague checking to prevent dispensing medication errors

Lack of mandatory end-of-day reconciliation of prescription-only drugs dispensed against prescriptions

Lack of policing of internal pharmacy error records

Lack of mandatory read-back procedures for dispensing details

Lack of central monitoring and trend analysis of prescription errors