PFD report

Joseph James Gingell · Prevention of Future Deaths report

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Issued 17 Feb 2020•Essex

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.

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Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

Described in responses

Recipients and published 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.

Concerns raised3

  1. Toxic effects from excessive amounts of drugs taken with other medication
    Part of recurring concern: Toxicity risks from excessive or combined medication use
  2. Permitting patients to opt out of GP notification
  3. Permitting patient self-certification without checks
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.4

  1. Action

    Continue working nationally, regionally and locally with key 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 24 February 2020.
  2. Action

    Coordinate a programme implementing Prescribed medicines review recommendations with relevant arm’s-length bodies to improve cross-system safety.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2020.
  3. Action

    Adopt a quality assurance, safety and security standards system for online consultations.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 24 February 2020.

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

  1. Position

    NHSE&I lacks powers to stop illegal supply of dependence-forming controlled drugs outside the legislative framework.

    Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.

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

Toxic effects from excessive amounts of drugs taken with other medication

Wider context from the report

“(1) The drugs found in Mr Gingell’s system are known to have toxic effects when taken in excessive amounts in conjunction with other medication. ”

Is this part of a recurring concern?

Yes — Toxicity risks from excessive or combined medication use.

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

Permitting patients to opt out of GP notification

Wider context from the report

“(3) Permitting the patient the option of not having a GP informed removes an otherwise effective safeguard. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Permitting patient self-certification without checks

Wider context from the report

“(2) Permitting the patient to “self certify” without any checks can allow abuse of the system by those most vulnerable who have addiction problems. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Continue working nationally, regionally and locally with key partners to improve controlled-drug and online-prescribing safety.

Verbatim wording from the response

“NHSE&I 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 who would be better placed should you wish to understand their work in this area further.”

Source location

Response from NHS England
Page 5 · response
Published 24 February 2020

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

Coordinate a programme implementing Prescribed medicines review recommendations with relevant arm’s-length bodies to improve cross-system safety.

Verbatim wording from the response

“In the wider context of this issue, Public Health England published in 2019 a Prescribed medicines review⁷. This reported on the evidence for dependence on, and withdrawal from, prescribed medicines with the aim of making sure that local healthcare systems build awareness and support to enhance clinician and patient decision making. In support of this NHSE&I are co-ordinating a programme to implement the review recommendations, working closely with relevant Arm’s Length Bodies (ALBs) to ensure cross system improvements. The programme covers five classes of medicines including:”

Source location

Response from NHS England
Page 5 · response
Published 24 February 2020

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 a quality assurance, safety and security standards system for online consultations.

Verbatim wording from the response

“One of the questions CQC’s inspectors asked during these inspections included how the service makes sure the identity of the patient is authenticated and requested that where a treatment might have the potential to affect safe care or decrease the ability of the patient’s GP to provide safe and effective care that the patient’s NHS GP is kept informed of any treatment, with the exception of sexual health services. These issues are important for NHSE&I 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. NHSE&I 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

Response from NHS England
Page 3 · response
Published 24 February 2020

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

Ensure NHS online consultations provide safe, secure access to appropriate clinicians connected with patients’ GP practices.

Verbatim wording from the response

“One of the questions CQC’s inspectors asked during these inspections included how the service makes sure the identity of the patient is authenticated and requested that where a treatment might have the potential to affect safe care or decrease the ability of the patient’s GP to provide safe and effective care that the patient’s NHS GP is kept informed of any treatment, with the exception of sexual health services. These issues are important for NHSE&I 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. NHSE&I 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

Response from NHS England
Page 3 · response
Published 24 February 2020

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

NHSE&I lacks powers to stop illegal supply of dependence-forming controlled drugs outside the legislative framework.

Verbatim wording from the response

“The sale or supply of controlled drugs outside of the legislative framework is the responsibility of the Home Office, and NHSE&I does not have powers to stop illegal supply of dependence forming drugs with toxic potential. However, we can and do take this into account in the provision of NHS services. NHSE&I expects all NHS providers to follow the NICE guidance on Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings² which directs people to consider the use of drugs, prescribed or otherwise when providing clinical care.”

Source location

Response from NHS England
Page 2 · response
Published 24 February 2020

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 Home Office is responsible for controlling the sale or supply of controlled drugs outside the legislative framework.

Verbatim wording from the response

“The sale or supply of controlled drugs outside of the legislative framework is the responsibility of the Home Office, and NHSE&I does not have powers to stop illegal supply of dependence forming drugs with toxic potential. However, we can and do take this into account in the provision of NHS services. NHSE&I expects all NHS providers to follow the NICE guidance on Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings² which directs people to consider the use of drugs, prescribed or otherwise when providing clinical care.”

Source location

Response from NHS England
Page 2 · response
Published 24 February 2020

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.1

  1. 1

    Provide patients with advice about the dangers of buying medicines online.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 24 February 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The CQC and MHRA are better placed to explain work addressing online prescribing and distance-selling safety concerns.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  2. 2

    The death appears not to have resulted from NHS services but from services provided 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 respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Provide patients with advice about the dangers of buying medicines online.

Verbatim wording from the response

“• NHSE&I provides advice⁶ to patients on the dangers of buying medicines on-line.”

Source location

Response from NHS England
Page 4 · response
Published 24 February 2020

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 CQC and MHRA are better placed to explain work addressing online prescribing and distance-selling safety concerns.

Verbatim wording from the response

“NHSE&I 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 who would be better placed should you wish to understand their work in this area further.”

Source location

Response from NHS England
Page 5 · response
Published 24 February 2020

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 not to have resulted from NHS services but from services provided 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 where 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.”

Source location

Response from NHS England
Page 5 · response
Published 24 February 2020

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

Data last updated 7 September 2026