York Road Pharmacy

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First report 16 Aug 2024•Latest report 16 Aug 2024

Reports, concerns and published responses

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
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
2

Described in responses

Concerns and recipient responses

Statements from York Road Pharmacy linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. County Durham and Darlington

    AI-generated summary

    Anthony Paul Nixon · 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

    Anthony Paul Nixon, aged 45, was found deceased at his home on 12 June 2023 after a drug overdose involving a combination of substances. The report identified concerns that a pharmacy supplied additional doses of a controlled drug in advance and contrary to the supervised-consumption prescription, leaving him in possession of multiple doses without notifying his drug treatment provider. The inquest concluded that the death was drug related and that the pharmacy’s actions contributed more than minimally by supplying the additional doses.

    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 York Road Pharmacy; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide supervised doses of a controlled drug in accordance with the prescription's specified days and doses

    Wider context from the report

    “(1) The Pharmacist in this case gave evidence that he believed that he had a discretion to provide ████████ in advance, and not in accordance with the prescription for supervised provision of ████████ on specific days, and maintained this was a “standard practice” when the Pharmacy was open for half a day on Saturdays. He interpreted the wording on the prescription namely “please dispense instalments due on a Pharmacy closed days on a prior suitable date” to include Saturdays when the Pharmacy was open for half a day, despite the prescriptions stipulating the specific days that the ████████ was to be provided, including specification of the dose each Saturday. (2) This led to a situation where the deceased was in possession of multiple doses of a controlled drug, namely ████████, on a regular basis in the period leading up to his death, which was not in accordance with the prescription, which had been carefully considered to attempt to manage the obvious risks of such. (3) The Pharmacy had been specifically chosen by the deceased’s drug treatment provider because it was able to provide supervised administration of ████████ on a 6 day per week basis and because in their assessment this was required to attempt to manage the risks inherent in the deceased having access to multiple doses. (4) The treatment provider were not alerted to the fact that the deceased was regularly receiving additional doses of ████████ not in accordance with the prescription they had issued, and so was unable to risk manage the suitability of the prescribing arrangements. (5) I was not reassured that the Pharmacist fully appreciates the gravity of this situation, and that in evidence he continued to maintain that he could exercise a discretion in relation to the provision of ████████, a controlled drug, and provide this not in accordance with specific prescription instructions on the days specified when the Pharmacy was open, and further that was described as a standard practice. (6) For the avoidance of doubt, the circumstances of this case have been alerted to the General Pharmaceutical Council, as the appropriate regulator, but there has been no update received as to whether an investigation has been undertaken or any action recommended. ”
    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 York Road Pharmacy; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to alert the drug treatment provider to dispensing outside the prescription

    Wider context from the report

    “(1) The Pharmacist in this case gave evidence that he believed that he had a discretion to provide ████████ in advance, and not in accordance with the prescription for supervised provision of ████████ on specific days, and maintained this was a “standard practice” when the Pharmacy was open for half a day on Saturdays. He interpreted the wording on the prescription namely “please dispense instalments due on a Pharmacy closed days on a prior suitable date” to include Saturdays when the Pharmacy was open for half a day, despite the prescriptions stipulating the specific days that the ████████ was to be provided, including specification of the dose each Saturday. (2) This led to a situation where the deceased was in possession of multiple doses of a controlled drug, namely ████████, on a regular basis in the period leading up to his death, which was not in accordance with the prescription, which had been carefully considered to attempt to manage the obvious risks of such. (3) The Pharmacy had been specifically chosen by the deceased’s drug treatment provider because it was able to provide supervised administration of ████████ on a 6 day per week basis and because in their assessment this was required to attempt to manage the risks inherent in the deceased having access to multiple doses. (4) The treatment provider were not alerted to the fact that the deceased was regularly receiving additional doses of ████████ not in accordance with the prescription they had issued, and so was unable to risk manage the suitability of the prescribing arrangements. (5) I was not reassured that the Pharmacist fully appreciates the gravity of this situation, and that in evidence he continued to maintain that he could exercise a discretion in relation to the provision of ████████, a controlled drug, and provide this not in accordance with specific prescription instructions on the days specified when the Pharmacy was open, and further that was described as a standard practice. (6) For the avoidance of doubt, the circumstances of this case have been alerted to the General Pharmaceutical Council, as the appropriate regulator, but there has been no update received as to whether an investigation has been undertaken or any action recommended. ”
    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

    Ensure all pharmacy staff understand the guidance and required procedures through internal discussion and consideration.

    Verbatim wording from the response

    “We have discussed these requirements internally and all staff are aware of the actions required and have considered the guidance fully. I have ensured that staff have fully understood the guidance and the steps we must take. The details of the”

    Source location

    Response from York Road Pharmacy
    Page 1 · response
    Published 19 August 2024

    Open published response

    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

    Implement the Drug and Alcohol Service guidance, including checking supervised-consumption days on agreements and notifying the service of changes.

    Verbatim wording from the response

    “We have found the Durham County Council Drug and Alcohol Service Briefing Note: October 2024 helpful in this regard. This briefing describes the flexibility provided by the standard Home Office wording on FP10(MDA) prescriptions, describes changes to the Pharmacy Treatment Agreement and provides an update on how pharmacies can contact the service.”

    Source location

    Response from York Road Pharmacy
    Page 1 · response
    Published 19 August 2024

    Open published response
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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