14 Oct 2025 Paula Doreen Hughes · Prevention of Future Deaths report Inner South London
View report summary
Concerns raised 7 Failure to prevent concurrent prescriptions of paracetamol-containing drugs View source Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity View source Lack of a mechanism for consistently recording pre-admission over-the-counter medications View source Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element View source Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews View source Lack of a robust process for managing therapeutic excess and potential toxicity View source Risk of loss or dilution of prescribing safety nets during electronic system changes View source See 4 more concerns
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AI-generated summary
Paula Doreen Hughes · 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
Paula Doreen Hughes was admitted to hospital after a fall and received paracetamol in excess of the recommended dose because paracetamol was prescribed alongside co-codamol. The overdose was not recognised until she had developed fulminant acute liver failure, and timely treatment was not provided. The principal concerns included preventing duplicate paracetamol prescriptions and administration, recognising and managing therapeutic excess, accurately assessing confusion, recording over-the-counter medicines, mitigating confirmation bias, and providing guidance for virtual patient reviews.
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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; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent concurrent prescriptions of paracetamol-containing drugs
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of robust mechanisms to mitigate confirmation bias and encourage professional curiosity
Wider context from the report “5. Trust approach to mitigating against confirmation bias and encouraging professional curiosity (LGT)
Confirmation bias and a lack of professional curiosity were significant features in Mrs Hughes’ being administered two paracetamol containing drugs at the same time and in not investigating whether she had received a therapeutic excess and suffered consequential harm. I have found that the Trust does not have robust mechanism for mitigating against confirmation bias and encouraging professional curiosity.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism for consistently recording pre-admission over-the-counter medications
Wider context from the report “4. Mechanism for recording over the counter medications taken prior to attendance at the Emergency Department (LGT)
This concern has arisen out of my finding that Mrs Hughes had taken an over the counter (OTC) drug containing paracetamol before her admission to hospital but that this had not been recorded as part of her medication history. The Trust’s Medicines Reconciliation Policy requires that patients should be asked about OTCs. The Trust relies on individual clinical practice. There is no mechanism to ensure that pre-admission OTCs are consistently recorded such that the risk of therapeutic excess of paracetamol (or other drugs available OTC) in those circumstances continues to exist.
” 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; that does not assign responsibility.
PFD Monitor interpretation Insufficient guidance for accurate and consistent assessment of the ACVPU confusion element
Wider context from the report “3. The assessment of the ACVPU score (LGT, RCP, NHSE)
This concern has arisen out of the fact that Mrs Hughes was scored as alert when she was confused. Confusion would have added a score of 3 to her NEWS2 score and would have resulted in an earlier escalation of her condition. I heard that confusion is not always easy to identify and that the signs can be subtle.
(1) LGT
The Trust provided training materials relating to detection and management of deteriorating patients. There was minimal guidance on how to accurately assess the ACVPU score and the confusion element in particular. There remains a tangible risk that the ACVPU score will continue to be assessed inconsistently, with new episodes of confusion continuing to be missed.
(2) NHSE, RCP
I consider that consistent and accurate assessment of the ACVPU element of the NEWS2 score is likely to a matter of wider concern. This concern is being brought to the attention of NHSE and the RCP as I consider that they have the power to support healthcare professionals to ensure consistent and accurate scoring of confusion.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance or policy for deciding when virtual reviews can replace face-to-face reviews
Wider context from the report “6. Trust policy on managing virtual patient reviews (LGT)
This concern has arisen out of the fact that Mrs Hughes had been reviewed virtually rather than face to face a resident doctor on the morning before she became unwell. The Trust has no guidance or policy on virtual reviews. I was told that this is a matter of clinical judgment. The absence of any guidance to help a still relatively inexperienced resident doctor decide when they can dispense with a face-to-face review is a circumstance that creates a risk that future deaths may occur.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust process for managing therapeutic excess and potential toxicity
Wider context from the report “2. Management of therapeutic excess if it has not been prevented (LGT)
This issue has arisen from the finding that once the concurrent prescription had been identified, there had no attempt to consider whether there had been a therapeutic excess and whether Mrs Hughes had suffered harm. The Trust’s response to the incident focused on prevention. It did not consider the adequacy of the clinical response once the overdose had been identified. The Trust relies on information sharing of learning from incidents and thereafter places reliance on individual clinical practice. I received no evidence of a robust process for ensuring a consistent clinical response to the management of therapeutic excess and the potential for toxicity.
” 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; that does not assign responsibility.
PFD Monitor interpretation Risk of loss or dilution of prescribing safety nets during electronic system changes
Wider context from the report “1. In respect of preventing concurrent prescriptions of paracetamol containing drugs and otherwise preventing prescribing errors resulting in therapeutic excess of paracetamol (NHSE, RPS, Cerner, MHRA, LGT)
(1) NHSE, RPS, Cerner, MHRA
I consider that the risk of concurrent prescriptions of paracetamol containing drugs is of wider national concern.
The Cerner prescribing system offers a duplicate checking functionality that is not a standard feature. It is hard stop and can be overridden and was not adopted by the LGT when the system was introduced. All the healthcare professionals were aware that co-codamol contained paracetamol and should not be prescribed with paracetamol. However, the 2 prescribing doctors failed to recognise that Mrs Hughes was already prescribed a paracetamol containing drug. 2 nurses failed to recognise they were administering 2 paracetamol containing drugs. A pharmacist failed to identify the concurrent prescriptions during reconciliation.
(2) LGT
LGT’s response to the incident was swift and commendable. A hard stop was introduced to the electronic prescribing system which eliminated concurrent prescriptions of paracetamol containing drugs. Further refinements of the system significantly reduced therapeutic excesses of paracetamol based on weight, which had been identified as an issue when investigating Mrs Hughes’ death. However, it is my understanding that consideration is being given to changing the electronic record and prescribing system. My concern is that during any move to a new system, the safety nets introduced by the Trust will be diluted or lost.
” Open source report
×
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 Building electronic prescribing alerts requires national oversight to coordinate work with secondary-care system suppliers.
Verbatim wording from the response “We believe that steps could be taken to try and build alerts and warnings for the unacceptable duplication of medicines in these electronic prescribing systems to make them safer. This would require national oversight to coordinate work with secondary care system suppliers.” Source location Response from Royal Pharmaceutical Society
Open published response
12 Jun 2025 Simon HOCKENHULL · Prevention of Future Deaths report Cheshire
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Concerns raised 2 Inconsistent definition of a month for diabetic medication supplies View source Lack of prescriber and dispenser awareness of medication supply duration issues View source
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AI-generated summary
Simon HOCKENHULL · 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
Simon Hockenhull died at home on 5 December 2024 after contracting lobar pneumonia, with underlying diabetes and diabetic gastro-enteropathy reducing his resilience. The report raises concerns that inconsistent interpretations of a 28-day supply as a “month” can delay repeat prescriptions for diabetic medication and devices, potentially leading to inconsistent medication use and serious health effects including diabetic ketoacidosis.
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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; that does not assign responsibility.
PFD Monitor interpretation Inconsistent definition of a month for diabetic medication supplies
Wider context from the report “In the course of this inquest, I have heard that some diabetic medications and devices have a life span of 14 days. When two are prescribed, they therefore amount to a 28 day supply.
I have heard that this can cause problems as there are some pharmacists who interpret a 28 day supply as a “month” , and that it can therefore be challenging to obtain a further prescription within the same calendar month . For patients who already have a complex relationship with their medication and monitoring regime, the challenges this causes can mean that they then do not take their medication as consistently as they need to. For patients with a diagnosis of diabetes, this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis.
At the heart of the issue seems to be that a “month” is being inconsistently defined. Sometimes it means 28 days, sometimes it is a calendar month .
The RCGP RPS “Repeat Prescription Toolkit” (October 2024) does not seem to address this issue, so it may be that prescribers and dispensers are unaware of this issue.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of prescriber and dispenser awareness of medication supply duration issues
Wider context from the report “In the course of this inquest, I have heard that some diabetic medications and devices have a life span of 14 days. When two are prescribed, they therefore amount to a 28 day supply.
I have heard that this can cause problems as there are some pharmacists who interpret a 28 day supply as a “month”, and that it can therefore be challenging to obtain a further prescription within the same calendar month. For patients who already have a complex relationship with their medication and monitoring regime, the challenges this causes can mean that they then do not take their medication as consistently as they need to. For patients with a diagnosis of diabetes, this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis.
At the heart of the issue seems to be that a “month” is being inconsistently defined. Sometimes it means 28 days, sometimes it is a calendar month.
The RCGP RPS “Repeat Prescription Toolkit” (October 2024) does not seem to address this issue , so it may be that prescribers and dispensers are unaware of this issue .
” 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 Raise awareness of the report through communications and engagement with medicines and patient safety stakeholders.
Verbatim wording from the response “Thank you for highlighting your concerns in this prevention of future death report. We will raise awareness of the report through our communications and engagement with other key medicines and patient safety stakeholders who play an important role in providing advice and support to the profession. It would also help if you and the family of Mr. Hockenhull were happy to give permission for us to see the full details of the case, in order to understand the details of what happened and if there is any further learning that could be shared with members of both the Royal Pharmaceutical Society and Royal College of General Practitioners.” Source location Response from Royal Pharmaceutical Society
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 Calendar-month dispensing is impractical because manufacturer pack sizes, licensing requirements and risks of splitting packs constrain supply.
Verbatim wording from the response “Calendar months in the year would be 28, 29 (leap year), 30 and 31 days, but this would be unworkable as previously mentioned, medication pack sizes are determined by the manufacturer and the licensing is based on the pack size submitted. Splitting some packs means the pharmacy would be supplying ‘off label’ which can bring separate issues around that. Again, these will vary depending on whether they are a “calendar” pack or a standard pack.” Source location Response from Royal Pharmaceutical Society
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 Specific prescription-duration guidance was outside the Repeat Prescribing Toolkit’s agreed scope, which was not intended as a clinical guideline.
Verbatim wording from the response “At the time of drafting the RCGP RPS Repeat Prescribing Toolkit, the Toolkit working group (made up of practicing GPs, Clinical Pharmacists, Patients, GP practice staff, NHS England policy leads and regulators), had been informed that NHS England may be exploring work on prescription duration and so it was agreed that specific guidance on prescription duration was out of scope for the toolkit. The toolkit was never intended to be a clinical guideline and so would not have addressed the specific issues that you have highlighted in this case. Annex A of the Toolkit (page 87) details what was within and outside of the scope of the Repeat Prescribing Toolkit.” Source location Response from Royal Pharmaceutical Society
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 Medication-ordering risks are not usually linked to 28-day versus 30-day duration.
Verbatim wording from the response “Whilst it is a risk that patients may forget to order their medication or order late or there is a delay in the prescription being issued from the GP practice or community pharmacy, it is not usually linked to the medication duration of 28 vs 30 days. It is worth noting that legislation permits the community pharmacist to issue an emergency supply of a patient’s regular medication following appropriate clinical checks.” Source location Response from Royal Pharmaceutical Society
Open published response
Concerns raised 4 Medication dispatch failing to allow mistakes to be noticed and remedied View source Placing the onus on the patient to remedy prescription errors when the pharmacy cannot be contacted View source Submission of subsequent prescriptions despite knowledge that the first prescription was cancelled or to be cancelled View source Failure or inability to ascertain prescription status before issuing a subsequent prescription View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Oliver James Billings · 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
Oliver James Billings, aged 22, was found deceased at home on 6 December 2023 after consuming possibly as many as 266 prescribed 75mg tablets. The report describes concerns that a second prescription was issued without confirming the status of the first, that rapid dispatch limited opportunities to identify or correct the error, and that Oliver was expected to remedy the problem when Pharmacy2U could not be contacted.
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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; that does not assign responsibility.
PFD Monitor interpretation Medication dispatch failing to allow mistakes to be noticed and remedied
Wider context from the report “(2) That the swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied .
” 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; that does not assign responsibility.
PFD Monitor interpretation Placing the onus on the patient to remedy prescription errors when the pharmacy cannot be contacted
Wider context from the report “(3) That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted .
” 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; that does not assign responsibility.
PFD Monitor interpretation Submission of subsequent prescriptions despite knowledge that the first prescription was cancelled or to be cancelled
Wider context from the report “(1) That a subsequent prescription was submitted in the knowledge that the first was cancelled or to be cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that prescription before the subsequent prescription was issued.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure or inability to ascertain prescription status before issuing a subsequent prescription
Wider context from the report “(1) That a subsequent prescription was submitted in the knowledge that the first was cancelled or to be cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that prescription before the subsequent prescription was issued .
” 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 Publish and make available the Repeat Prescribing Toolkit with guidance on reviewing and safely managing high-risk repeat medicines.
Verbatim wording from the response “High risk medicines and vulnerable patients
The recently published Royal College of General Practitioners and RPS Repeat Prescribing Toolkit¹, advises GPs to think carefully about their arrangements for repeat prescribing of medicines. Patients should be offered regular and careful review of their medicines and the decision to prescribe high-risk medicines should always be considered on an individual basis.” Source location Response from Royal Pharmaceutical Society
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 The benefits of efficient, timely medicine supply outweigh the risks because prescribers should complete clinical appropriateness assessments before issuing prescriptions.
Verbatim wording from the response “Dispensing and supply of medicines from a community pharmacy
The coroner’s report refers to the ‘swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied’. It is worth noting that under the NHS Community Pharmacy Contractual Framework Essential Service – Dispensing, there is a contractual obligation for community pharmacies in England to dispense medication for patients with reasonable promptness. Medicines optimisation is about ensuring that the right patient receives the right medicine at the right time. All assessments of the clinical appropriateness of a medication by a prescriber should be complete before issuing the prescription, therefore the subsequent benefits of a safe and timely supply of medicines would outweigh risks of supplying medicines efficiently.” Source location Response from Royal Pharmaceutical Society
Open published response
16 Jul 2024 Jessica de Souza · Prevention of Future Deaths report Surrey
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Concerns raised 1 Failure to ensure aripiprazole monotherapy is effective for prophylaxis against both bipolar polarities View source
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.
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AI-generated summary
Jessica de Souza · 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
Jessica de Souza, who had bipolar disorder, developed depression after a family bereavement and took her own life by hanging at home on 1 February 2023. Concerns included that aripiprazole was prescribed as monotherapy for both polarities of bipolar disorder, although expert evidence stated it was not effective prophylaxis against depressive relapse. The expert also considered that the guidance relied on by clinicians may have been misleading.
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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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure aripiprazole monotherapy is effective for prophylaxis against both bipolar polarities
Wider context from the report “i. The treating psychiatrists gave evidence that, following the acute manic episode, Jessica was prescribed aripiprazole as a maintenance prophylactic drug to control both polarities of bipolar disorder.
ii. The clinicians relied on the BNF and the BMJ Best Practice Bipolar Disorder in Adults to support their decision to prescribe aripiprazole as prophylaxis for both polarities as a monotherapy.
iii. Nice Guidance on Bipolar Disorder [CG185] suggests aripiprazole may be considered as a maintenance treatment to prevent relapse in bipolar disorder.
iv. The BMJ refers to aripiprazole being used as a monotherapy to treat bipolar disorder, though does advise that it is more effective in preventing mania than depression.
v. The court appointed psychiatric expert gave evidence that aripiprazole is not effective as a prophylaxis in relation to the depressive polarity in bipolar and that as a result Jessica was not protected from a depressive relapse.
vi. The expert considered that the guidance relied on may have been misleading for the clinicians.
” Open source report
5 May 2023 Joshua Asprey · Prevention of Future Deaths report East Sussex
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Concerns raised 1 Failure of sertraline BNF information to identify the risk of suicidal behaviour View source
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.
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AI-generated summary
Joshua Asprey · 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
Joshua Asprey, aged 19, died on 14 June 2021 from multiple injuries after deliberately jumping from a cliff; the inquest recorded a conclusion of suicide. The report raised concern about inconsistencies between the sertraline patient information leaflet and the British National Formulary regarding the risk of suicidal behaviour, and the potential for prescribers to be unaware of or fail to discuss that risk.
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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; that does not assign responsibility.
PFD Monitor interpretation Failure of sertraline BNF information to identify the risk of suicidal behaviour
Wider context from the report “1. The evidence heard during the course of the inquest highlighted an inconsistency between the literature provided by the manufacturer of sertraline (the patient information leaflet (‘PIL’)) and the British National Formulary (‘BNF’) produced by the Royal Pharmaceutical Society (latest version: BNF 85, March 2023).
2. The PIL contains a list of “uncommon” side effect of suicidal behaviour , which includes the following in bold: “Cases of suicidal ideation and suicidal behaviours have been reported during sertraline therapy or early after treatment discontinuation (see section 2).”
3. The BNF relating to Depression (3.4, p395) and the use of Antidepressant Drugs states under the heading “Suicidal depression and antidepressant therapy” (p397): “The use of antidepressants has been linked with suicidal thoughts and behaviour; children young adults and patients with a history of suicidal behaviour and particularly suicidal behaviour are particularly at risk. Where necessary patients should be monitored for suicidal behaviour, self-harm or hostility, particularly at the beginning of treatment or if the dose is changed.”
4. The section of the BNF relating to SSRIs (p401) also identifies “suicidal behaviours” as a potential uncommon side-effect.
5. However, the section with respect to sertraline does not specifically identify suicidal tendencies at all , although it does identify “thinking abnormal” as an uncommon side effect (p.405).
6. I am concerned that there is a risk that a medical practitioner consulting the BNF with a view to determining dosage and treatment with Sertraline will be unaware of the potential risk of the onset of suicidal behaviour and/or would not consider it necessary to discuss that risk with the patient . The evidence heard at the inquest suggested that it would not be appropriate or practical for GPs to consider PILs before prescribing.
7. On the other hand, the PIL and BNF are intended for different purposes. It may be that the evidence of risk of suicidal ideation associated with Sertraline specifically (as opposed to SSRIs) is so low that it need not be referred to in the BNF, notwithstanding its inclusion in the PIL. Nevertheless, this is a matter of concern that would in my view benefit from further consideration.
” Open source report
Concerns raised 1 Failure of nitrofurantoin prescribing guidance to provide advice on monitoring for sudden pulmonary deterioration during short-term treatment in elderly patients View source
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Jane Elizabeth ALLISON · 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
Jane Elizabeth ALLISON died in hospital on 20 November 2021 after being admitted with severe type 1 respiratory failure. She had received a 10-day course of nitrofurantoin for a urinary tract infection, and the inquest concluded that she died from the effects of prescribed medication. The principal concern was that BNF guidance did not sufficiently alert clinicians to the risk of sudden pulmonary deterioration or provide adequate monitoring advice in this circumstance.
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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; that does not assign responsibility.
PFD Monitor interpretation Failure of nitrofurantoin prescribing guidance to provide advice on monitoring for sudden pulmonary deterioration during short-term treatment in elderly patients
Wider context from the report “In effect, my concern is that the BNF content had not advised to be alerted to the danger of sudden pulmonary deterioration in an elderly patient , and certainly not one who was fit and active, and not in the context of the duration of a prescribing, dispensing and administration period of only 10 days. Effectively, the BNF content did not cover the eventuality of this case in that it was deficient in providing advice as to monitoring and being alert for pulmonary failure .
” 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 Update the nitrofurantoin monograph with highlighted information on acute pulmonary reactions, including patient counselling and prompt symptom reporting.
Verbatim wording from the response “We have reviewed the BNF content for nitrofurantoin in response to your report and can confirm that we will add additional information regarding acute pulmonary reactions to the nitrofurantoin monograph in the BNF. To increase awareness of this side-effect, we will highlight it specifically in an additional section of the side-effects information. We will also add information on the importance of counselling patients on the possible symptoms of acute pulmonary reactions and the necessity of promptly reporting such symptoms. This will mean that the risk of acute pulmonary reactions will be highlighted in the nitrofurantoin monograph in future.” Source location 2022-0071-Response-from-Royal-Pharmaceutical-Society_Published
Open published response
Concerns raised 2 Lack of national guidance or standards for sharing medication risk information and care plans with local pharmacies View source Failure to ensure appropriate pharmacy involvement in medication safety plans for mental health patients aged 16–17 View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
SAMANTHA JANE GOULD (Sam) · 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
Sam took a very large quantity of prescribed medication at home in the early hours of 2 September 2018 and died within at most a couple of hours. The local pharmacy had not been told about a safety plan under which Sam’s parents were responsible for her medication. The report identified a concern that, without national action to ensure pharmacies are involved in medication safety plans for mental health patients aged 16–17, similar fatalities could occur.
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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; that does not assign responsibility.
PFD Monitor interpretation Lack of national guidance or standards for sharing medication risk information and care plans with local pharmacies
Wider context from the report “(1) There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
(2) A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
However,
(3) I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16 – 17, given that such patients may otherwise be able to obtain prescribed medication with which to overdose.
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate pharmacy involvement in medication safety plans for mental health patients aged 16–17
Wider context from the report “(1) There did not appear to be any national guidance or standards that directed or encouraged appropriate sharing of risk information and care plans with the local pharmacy. As a result, the pharmacy was unsighted on the fact that the treating psychiatric team had a safety plan involving Sam’s parents being responsible for handling and administering all medication. Had the pharmacy been aware of this plan, it is likely that they would have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or General Practitioner.
(2) A local protocol has now been introduced whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent Mental Health Service ensures that any pharmacy used regularly by their patients aged 16-17 are (where appropriate) advised of relevant care plans, as well as the responsible GP being so informed. This is now to be part of mandatory training for CAMHS prescribing staff and is to be discussed in the local Joint Prescribing Group to ensure better communication between the local NHS Trusts, G.P.s and local pharmacies. Accordingly, action has already been taken in the local area to prevent similar fatalities.
However,
(3) I am concerned that there is a risk of future fatalities if action is not taken at a national level to ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16 – 17 , given that such patients may otherwise be able to obtain prescribed medication with which to overdose .
” 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 Publish a policy and position statement on patient health records.
Verbatim wording from the response “This is an active area in which the RPS continues to campaign. We believe access and sharing of patient health records for community pharmacies is really important and recognising pharmacists have a legitimate need to access patient health records to improve patient outcomes for patients.” Source location 2021-0186-Response-from-RPS_Published-1
Open published response
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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 Publish guidance on keeping patients safe when they transfer between care providers.
Verbatim wording from the response “We have also published guidance around keeping patients safe when they transfer between care providers. This is available on our website.
https://www.rpharms.com/resources/quick-reference-guides/keeping-patients-safe” Source location 2021-0186-Response-from-RPS_Published-1
Open published response
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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 Continue campaigning for community-pharmacy access to and sharing of patient health records.
Verbatim wording from the response “This is an active area in which the RPS continues to campaign. We believe access and sharing of patient health records for community pharmacies is really important and recognising pharmacists have a legitimate need to access patient health records to improve patient outcomes for patients.” Source location 2021-0186-Response-from-RPS_Published-1
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 Mandating local adoption of national protocols across the NHS and other care providers is outside the respondent’s role.
Verbatim wording from the response “It would not be within the scope of our role to mandate local changes are adopted across the NHS and by other care providers, however we recognise the need for community pharmacies to be involved in the development of medication safety plans. If changes can be made by the relevant NHS organisations to ensure pharmacy teams are involved in this process, we will raise awareness of this amongst the pharmacy profession.” Source location 2021-0186-Response-from-RPS_Published-1
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 NHS and CAMHS organisations are responsible for making changes to prevent deaths involving pharmacy communication and medication safety plans.
Verbatim wording from the response “We believe that there is a need for more system leadership in this area noting that pharmacies are often the recipients of information. This Regulation 28 report has been addressed to pharmacy organisations, and there is parallel need for organisations representing the NHS and CAMMHS services to make changes to prevent deaths.” Source location 2021-0186-Response-from-RPS_Published-1
Open published response
Concerns raised 2 Availability of prescription drugs in vast quantities for illegal dealing to vulnerable people View source Failure to prevent prescription medication leakage from the lawful dispensing process into criminal hands View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Claire RICHARDS · 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
Claire Richards had a history of drugs misuse and mental health issues and died at home after snorting illegally dealt pregabalin and buprenorphine, becoming unresponsive despite emergency services being summoned. The principal concern was the availability of prescription drugs in large quantities for illegal dealing to vulnerable people and the leakage of prescription medication from lawful dispensing into criminal hands.
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; that does not assign responsibility.
PFD Monitor interpretation Availability of prescription drugs in vast quantities for illegal dealing to vulnerable people
Wider context from the report “(1) This case involves a death resulting from illegally dealt prescription drugs. It is of increasing concern that prescription drugs are available in vast quantities for illegal dealing to vulnerable people .
” 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; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent prescription medication leakage from the lawful dispensing process into criminal hands
Wider context from the report “(1) This case involves a death resulting from illegally dealt prescription drugs. It is of increasing concern that prescription drugs are available in vast quantities for illegal dealing to vulnerable people .
(2) What steps are projected, or are actually in the pipe line, for stemming the leakage of prescription medication out of the lawful dispensing process into criminal hands ?
” Open source report
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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 PHE and ACMD are the appropriate bodies to address concerns about prescription-drug misuse and medicine availability.
Verbatim wording from the response “The report outlined matters of concern including the availability of prescription medicines to vulnerable people illegally, or outside of the healthcare system and controls on availability. For this reason we believe it would be appropriate for Public Health England (PHE) and the Advisory Council for the Misuse of Drugs (ACMD), who both have roles around the misuse of drugs to be aware of this report.” Source location 2020-0253-Response-from-Royal-Pharmaceutical-Society-Redacted.pdf
Open published response
10 Dec 2019 Brenda Anne Drew · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 1 Failure of pharmacists to obtain patients’ wishes before requesting repeat prescriptions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Brenda Anne Drew · 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
Brenda Anne Drew, who was partially sighted, fell at home in November 2018 and was prescribed Oramorph after sustaining a wrist fracture. She was found collapsed and unresponsive at home on 6 April 2019, and toxicology found a fatal level of morphine in her blood. The principal concerns were that repeat Oramorph prescriptions were issued without a formal review or confirmation of her wishes, including requests made by a pharmacy without consultation with the patient.
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; that does not assign responsibility.
PFD Monitor interpretation Failure of pharmacists to obtain patients’ wishes before requesting repeat prescriptions
Wider context from the report “iii. Evidence however was given by ████████ that there was concern that Pharmacists seem to request repeat prescriptions for medications without seeking the views of patients . Mrs Drew’s family explained at the Inquest that she had not been asked about the continued prescription of Oramorph. There is therefore a risk that patients may have access to medications without requesting it , as occurred with Mrs Drew. It was explained at the Inquest that this is a common concern as it appears to occur regularly.
2. I have concerns with regard to the following:
i. I am concerned that prescriptions are being requested from GPs by Pharmacists without consultations with patients or having been requested by patients . I would therefore request that consideration be given to providing guidance to all pharmacists in England and Wales that when making a request for a prescription to GPs, they should ensure the wishes of the patient are obtained, save in circumstances where this is not possible, such as where the patient lacks capacity.
” 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 Continue raising awareness of the pharmacy-team guidance and encouraging its continuing and further adoption.
Verbatim wording from the response “We will continue to help raise awareness and to encourage continuing and further adoption of the guidance by pharmacy teams.” Source location 2019-0421-Response-by-RPS_Redacted
Open published response
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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 Publish guidance for pharmacy teams on safely managing repeat prescription requests, including consent, clinical appropriateness, contact, adherence, quantities and audit trails.
Verbatim wording from the response “Guidance for pharmacy teams
Your letter recommended we produce guidance for pharmacists covering requests for prescriptions to GPs and we would like to confirm that we published guidance in this area in 2015. A copy is included with this response.” Source location 2019-0421-Response-by-RPS_Redacted
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 regulating pharmacy and pharmacy professionals rests with the General Pharmaceutical Council, not this organisation.
Verbatim wording from the response “As you may know the Royal Pharmaceutical Society (‘RPS’) is the professional body for pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. Our role is to lead and support the development of the pharmacy profession. We transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 2010, and they now regulate pharmacy and pharmacy professionals in Great Britain. Their contact details are: General Pharmaceutical Council, 25 Canada Square, London, E14 5LQ, phone: 0203 713 8000 and email: info@pharmacyregulation.org. You may wish to contact them separately if you haven’t already done so.” Source location 2019-0421-Response-by-RPS_Redacted
Open published response
Concerns raised 3 Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR View source Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals View source Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction View source
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.
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AI-generated summary
Patricia Margaret Thomas · 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
Patricia Margaret Thomas died at Morriston Hospital on 30 October 2013 after suffering an intracerebral haemorrhage, following an episode of unresponsiveness and left-sided weakness. The report identified a potential interaction between Miconazole Gel and Warfarin, a lack of awareness of this interaction among health professionals, and possible difficulties locating clear interaction-checking resources.
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; that does not assign responsibility.
PFD Monitor interpretation Potential for Miconazole Gel and Warfarin interaction causing increased blood clotting time and INR
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” 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; that does not assign responsibility.
PFD Monitor interpretation Lack of knowledge of the Miconazole Gel and Warfarin interaction among health professionals
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” 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; that does not assign responsibility.
PFD Monitor interpretation Unclear or difficult-to-locate resources for checking the Miconazole Gel and Warfarin interaction
Wider context from the report “It became apparent in the course of the evidence that
(1) There is a potential for Miconazole Gel to have an interaction with Warfarin such as to increase the blood clotting time and hence a higher INR reading than should be expected. This could lead to significant uncontrolled bleeding.
(2) There is a significant lack of knowledge of the interaction among health professionals and/or
(3) The resources available to check the interaction may not be entirely clear on this issue or readily straight forward to locate.
” Open source report
29 Feb 2016 Derrick Twaite · Prevention of Future Deaths report South Lincolnshire
View report summary
Concerns raised 1 Failure to comply with professional advice against placing snipped tablets in multi-dose compliance aids View source
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
Derrick Twaite · 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
Derrick Twaite swallowed a Finasteride tablet that remained in a sharp-edged bubble-pack segment, causing a gut perforation that led to his death. The report raised concern that tablets were still being snipped from unit-dose packs and placed in multi-dose compliance aids despite advice from relevant professional bodies.
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; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with professional advice against placing snipped tablets in multi-dose compliance aids
Wider context from the report “1. That although this practice of snipping tablets from the unit dose packs, still in their bubble, and place them in the compartments of multi-dose compliance aids is contrary to the advice of the relevant professional bodies , it apparently still being done by dispensing pharmacists and dispensing general practices ..
” Open source report
9 Jan 2015 Annette Charlton · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 1 Almost identical medication boxes View source
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
Annette Charlton · 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
Annette Charlton, who had emphysema and lung fibrosis requiring continuous oxygen therapy, was dispensed Naproxen instead of prescribed antibiotics and died on 28 September 2014. The principal concern was that medication manufacturers used almost identical packaging, which was considered likely to contribute to dispensing errors and potentially patient deaths.
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; that does not assign responsibility.
PFD Monitor interpretation Almost identical medication boxes
Wider context from the report “(1) Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.
” 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