PFD report

Ava Grace HODGKINSON · Prevention of Future Deaths report

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Issued 10 Jan 2025•Lancashire and Blackburn with Darwen

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 raised1

  1. Restrictions preventing pharmacists from issuing equivalent medication strengths to provide the same dose
    Part of recurring concern: Failure to provide required medication promptly when clinically needed
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

    Explore new flexibilities allowing pharmacists, in appropriate circumstances, to supply alternative doses or formulations.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.
  2. Action

    Conduct and publish a public consultation on proposed medication-supply flexibilities, subject to governmental clearances and Northern Ireland involvement.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 13 January 2025.

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

Restrictions preventing pharmacists from issuing equivalent medication strengths to provide the same dose

Wider context from the report

“(1) In evidence at the inquest it was explained that the Ava had seen her GP who had prescribed amoxicillin with a dose of 250mg/5ml. The pharmacy did not have this strength in stock but did have amoxicillin 125mg/5ml in stock but could not issue this as restrictions currently in place prevent a pharmacist issuing any different strength of medication without an amended prescription, even where the medication can be provided to enable the same dose to be administered (here Ava's parents could have been instructed to provide 10ml enabling the same dose of antibiotics to be provided). This led to a delay in Ava receiving antibiotics. Evidence from the Department of Health and Social Care included that this issue was being actively considered but it was explained the issue was complex and any change was likely to need public consultation and ministerial support. It was also explained that it was not possible to provide any timeframe for any appropriate steps to be taken to consider changing the restrictions preventing pharmacists from issuing medication where they can provide the same dosage of the same medication in a different denomination. ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed.

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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

Explore new flexibilities allowing pharmacists, in appropriate circumstances, to supply alternative doses or formulations.

Verbatim wording from the response

“Nevertheless, I am committed to my officials exploring new flexibilities. There has been a recent programme of engagement, since December 2024, as part of which my officials have discussed possibilities with stakeholders such as GP representatives, pharmacy bodies and patient groups. The stakeholder feedback has been sufficiently positive that the Government is minded, subject to the normal machinery of Government clearance processes, to proceed to a formal, public consultation.”

Source location

Response from DHSC
Page 2 · response
Published 13 January 2025

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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

Conduct and publish a public consultation on proposed medication-supply flexibilities, subject to governmental clearances and Northern Ireland involvement.

Verbatim wording from the response

“Nevertheless, I am committed to my officials exploring new flexibilities. There has been a recent programme of engagement, since December 2024, as part of which my officials have discussed possibilities with stakeholders such as GP representatives, pharmacy bodies and patient groups. The stakeholder feedback has been sufficiently positive that the Government is minded, subject to the normal machinery of Government clearance processes, to proceed to a formal, public consultation.”

Source location

Response from DHSC
Page 2 · response
Published 13 January 2025

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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

    Engage GP representatives, pharmacy bodies and patient groups on possible medication-supply flexibilities.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.

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

Engage GP representatives, pharmacy bodies and patient groups on possible medication-supply flexibilities.

Verbatim wording from the response

“Nevertheless, I am committed to my officials exploring new flexibilities. There has been a recent programme of engagement, since December 2024, as part of which my officials have discussed possibilities with stakeholders such as GP representatives, pharmacy bodies and patient groups. The stakeholder feedback has been sufficiently positive that the Government is minded, subject to the normal machinery of Government clearance processes, to proceed to a formal, public consultation.”

Source location

Response from DHSC
Page 2 · response
Published 13 January 2025

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