Summary
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Evidence
Reports, concerns and published responses Receiving a report does not make the recipient responsible for every concern in it. PFD Monitor does not verify whether stated actions happened.
Reports over time Reports naming this recipient by issue year.
* 2026 is projected from reports observed to 7 Sep 2026.
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
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
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
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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· Data reviewed 7 Sep 2026 · About data quality and limitations
Data last updated 7 September 2026
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations