PFD report

Jennifer Anne Lacey · Prevention of Future Deaths report

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Issued 24 Oct 2018•Inner West London

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
4

Raised in this report

Recipients
4

Named on the report

Responses found
1

Of 4 recipients

Stated actions
5

Described in responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Report evidence summary

Concerns raised4

  1. Unrestricted internet availability of potentially dangerous and addictive drugs
    Part of recurring concern: Inadequate safeguards for access to dangerous drugs
  2. Failure to perform further checks when filling prescriptions for potentially dangerous and addictive drugs in UK pharmacies
    Part of recurring concern: Inadequate safeguards for access to dangerous drugs
  3. Failure to access the patient’s medical records before prescribing potentially dangerous and addictive drugs
    Part of recurring concern: Unreliable access to relevant clinical records for safe carePart of recurring concern: Unsafe medication prescribing
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Work with other health regulators to address patient-safety risks from remote consultations and distance-selling medicine supply.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2019.
  2. Action

    Ensure NHS online consultations provide safe, secure access to an appropriate clinician connected with the patient’s GP practice.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 February 2019.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The death appears unrelated to NHS services because the consultation, prescription and medication were obtained outside the NHS.

    Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Unrestricted internet availability of potentially dangerous and addictive drugs

Wider context from the report

“1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards for access to dangerous drugs.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to perform further checks when filling prescriptions for potentially dangerous and addictive drugs in UK pharmacies

Wider context from the report

“1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”

Is this part of a recurring concern?

Yes — Inadequate safeguards for access to dangerous drugs.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to access the patient’s medical records before prescribing potentially dangerous and addictive drugs

Wider context from the report

“1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care; Unsafe medication prescribing.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to contact the patient’s regular medical practitioner before prescribing potentially dangerous and addictive drugs

Wider context from the report

“1. That such potentially dangerous and addictive drugs are so freely available over the internet. 2. That they can be prescribed without any contact with the patient’s regular medical practitioner or access to the patient’s medical records. 3. That such prescriptions of such potentially dangerous and addictive drugs may be being filled in UK pharmacies without any further checks. ”

Is this part of a recurring concern?

Yes — Unsafe medication prescribing.

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

Work with other health regulators to address patient-safety risks from remote consultations and distance-selling medicine supply.

Verbatim wording from the response

“With regard to this case, and based on the information provided within the Regulation 28, it appears that this death was not the result of services provided by NHS, but from services outside of the NHS. It is unclear whether this doctor or company were registered and the site from which the deceased obtained the consultation, prescription and medication. Nevertheless, the provision of remote consultations and the supply of medicines through distance selling remains a concern. We are working with other health regulators who have a greater role in responding to this challenge.”

Source location

2018-0315-Response-by-NHS-England
Page 3 · response
Published 23 February 2019

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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

Ensure NHS online consultations provide safe, secure access to an appropriate clinician connected with the patient’s GP practice.

Verbatim wording from the response

“These issues are important for NHS England and we will ensure that NHS online consultations provide a safe and secure way for patients to discuss their health concerns with an appropriate clinician connected to their own GP practice and place centred around their needs. NHS England has adopted a robust system of quality assurance, safety and security standards so that patients and clinicians can feel confident in using online consultations.”

Source location

2018-0315-Response-by-NHS-England
Page 2 · response
Published 23 February 2019

Open published response

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 death appears unrelated to NHS services because the consultation, prescription and medication were obtained outside the NHS.

Verbatim wording from the response

“With regard to this case, and based on the information provided within the Regulation 28, it appears that this death was not the result of services provided by NHS, but from services outside of the NHS. It is unclear whether this doctor or company were registered and the site from which the deceased obtained the consultation, prescription and medication. Nevertheless, the provision of remote consultations and the supply of medicines through distance selling remains a concern. We are working with other health regulators who have a greater role in responding to this challenge.”

Source location

2018-0315-Response-by-NHS-England
Page 3 · response
Published 23 February 2019

Open published response

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

CQC and MHRA are better placed to explain and address online prescribing safety work.

Verbatim wording from the response

“NHS England remains committed to improving the safety of controlled drugs and online prescribing. We will continue to work across the system with key partners nationally, regionally and locally to ensure patient safety. We would also suggest that contact is made directly with the CQC and MRHA would be better placed should you wish to understand the work in this area further.”

Source location

2018-0315-Response-by-NHS-England
Page 3 · response
Published 23 February 2019

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Hold a workshop on online primary care services and online prescribing to identify patient-safety and regulatory challenges.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
  2. 2

    Adopt quality-assurance, safety and security standards for NHS online consultations.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 February 2019.
  3. 3

    Continue working with national, regional and local partners to improve controlled-drug and online-prescribing safety.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 February 2019.

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

Hold a workshop on online primary care services and online prescribing to identify patient-safety and regulatory challenges.

Verbatim wording from the response

“However, we are aware of cases where coroners have highlighted an online consultation with a doctor, issue of a prescription and supply of medicines, as having contributed to a death. We recognise further work is needed to ensure patient safety where consultations are given online. As a result, in April 2017, the National Quality Board² - jointly chaired by NHS England and CQC - held a workshop focusing on online providers of primary care services and online prescribing. The workshop identified a number of challenges for the system including gaps in the current regulatory framework to protect patients from harmful practice. Following the workshop, the CQC established a UK-wide forum to review the regulatory landscape for online prescribing.”

Source location

2018-0315-Response-by-NHS-England
Page 2 · response
Published 23 February 2019

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

Adopt quality-assurance, safety and security standards for NHS online consultations.

Verbatim wording from the response

“These issues are important for NHS England and we will ensure that NHS online consultations provide a safe and secure way for patients to discuss their health concerns with an appropriate clinician connected to their own GP practice and place centred around their needs. NHS England has adopted a robust system of quality assurance, safety and security standards so that patients and clinicians can feel confident in using online consultations.”

Source location

2018-0315-Response-by-NHS-England
Page 2 · response
Published 23 February 2019

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

Continue working with national, regional and local partners to improve controlled-drug and online-prescribing safety.

Verbatim wording from the response

“NHS England remains committed to improving the safety of controlled drugs and online prescribing. We will continue to work across the system with key partners nationally, regionally and locally to ensure patient safety. We would also suggest that contact is made directly with the CQC and MRHA would be better placed should you wish to understand the work in this area further.”

Source location

2018-0315-Response-by-NHS-England
Page 3 · response
Published 23 February 2019

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026