27 Jan 2014 Judith Lesley Marshall · Prevention of Future Deaths report York City
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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
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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Judith Lesley Marshall · Prevention of Future Deaths report
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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.
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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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations