Recipient

The Company Chemists' Association

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First report 28 May 2021•Latest report 28 May 2021

Recipient record

Reports, concerns and published responses

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
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from The Company Chemists' Association linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cambridgeshire and Peterborough

    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.

    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 The Company Chemists' Association; 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 The Company Chemists' Association; 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
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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

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

How actions were described at the time

This respondent
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