Recipient

Well Pharmacy

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First report 12 Oct 2017•Latest report 12 Oct 2017

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company. 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 Well Pharmacy linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Nottinghamshire

    AI-generated summary

    Douglas Hodges · 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

    Douglas Hodges died in hospital on 3 April 2017 after developing multiple organ failure and systemic sepsis; antibiotics prescribed by his GP had not been dispensed by the pharmacy. The principal concerns were that community pharmacy systems did not communicate prescription urgency at the point of downloading, and that a prescription could be mislaid or accidentally disposed of without detection, creating a risk of future 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 Well Pharmacy; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure continuation of prescription safety controls after trial completion

    Wider context from the report

    “In relation to Wells Pharmacy : 1. I heard evidence from the patient safety manager of Wells Pharmacy Group, who told us they are trialling a system which includes the following provisions : a. Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day. We were told that urgency and delivery instructions would then be picked up at the labelling stage. b. Pharmacists are required to check at the end of each day whether there are prescriptions which have been sent to print but not yet got to the labelling stage. c. If a patient or representative comes in to collect prescribed medication, only one prescription will be downloaded at a time, to avoid any confusion. d. Local GPs will be made more aware of likely / realistic timescales between prescription and the medication going to patients. 2. I note that this trial will end in November. Whilst it is entirely appropriate to trial any change like this, there is no guarantee that changes will be implemented after the trial. I would like to know what the intention of the pharmacy is after the trial period ends, and how it proposes to reduce this risk in future. ”
    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 Well Pharmacy; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of communication of clinical urgency when prescriptions are downloaded

    Wider context from the report

    “In relation to NHS Digital : 1. As matters stand, in a community pharmacy setting, there is no way of communicating clinical urgency between prescriber and pharmacy staff at the time the prescription is downloaded. A large number of prescriptions are downloaded every day by pharmacies. Urgent and non-urgent prescriptions look the same on the system. It is only at the labelling stage that any clinicians’ comments can be seen. 2. We were told that a different system (Vision) is used in scenarios where a pharmacy is run by a GP practice. This system is often used in rural settings. The Vision system allows for a prescription to be marked with a red exclamation mark at the point of downloading, where a prescription is urgent. 3. Where prescriptions go via the NHS Spine, such a system is not currently possible. 4. We heard evidence about a recent survey conducted by NHS Digital, in which pharmacists made it clear that this was the change they most wanted to see. 5. It is clear that agreed guidelines will need to be considered, in line with any such change, to define what is meant by the term ‘urgent’. 6. Prof Hodges’ case makes the case for this change very clearly, and I consider there is a real risk of future deaths if this is not addressed. ”
    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 Well Pharmacy; that does not assign responsibility.

    PFD Monitor interpretation

    Inaccurate help information about unavailable prescription urgency functionality

    Wider context from the report

    “In relation to Cegedim : 1. During the investigation, an experienced clinical pharmacist who works at the GP practice attended the pharmacy and looked at the system in question. When accessing the ‘help section’ of the software, the information she saw suggested that the red exclamation mark system was available and she questioned why this was not being used. It is not clear why this information is included in the ‘help section’ of software that does not currently support this function. It clearly led to confusion. I ask that Cegedim review this and consider clarifying it. ”
    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