PFD report

Jamie Francis O'Connor · Prevention of Future Deaths report

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Issued 21 Oct 2021•Leicester City and South Leicestershire

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
8

Raised in this report

Recipients
5

Named on the report

Responses found
4

Of 5 recipients

Stated actions
16

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 raised8

  1. Failure to protect questionnaire answers from alteration
    Part of recurring concern: Failure to verify patient suitability before online sale of restricted medicines
  2. Failure to flag refusal to share prescribing information for further enquiry
    Part of recurring concern: Unsafe management of refusal of necessary care or protective actionPart of recurring concern: Unsafe medication prescribing
  3. Lack of central tracking of prescribed and dispensed drugs
    Part of recurring concern: Failure to reliably reconcile prescribed and dispensed medication
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.11

  1. Action

    Publish guidance for pharmacist prescribers on sharing prescribing information with people’s prescribers and other care professionals.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
  2. Action

    Enforce pharmacy standards by taking action against unsafe online medicine supply, including improvement notices and registration conditions.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
  3. Action

    Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.7

  1. Position

    A central system or database tracking prescribed and dispensed medicines, and the responsible individuals, is outside the remit.

    Stated by General Pharmaceutical CouncilOutside 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

Failure to protect questionnaire answers from alteration

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

Is this part of a recurring concern?

Yes — Failure to verify patient suitability before online sale of restricted medicines.

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 flag refusal to share prescribing information for further enquiry

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

Is this part of a recurring concern?

Yes — Unsafe management of refusal of necessary care or protective action; 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

Lack of central tracking of prescribed and dispensed drugs

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

Is this part of a recurring concern?

Yes — Failure to reliably reconcile prescribed and dispensed medication.

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

Lack of required face-to-face consultation before dispensing drugs

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

Is this part of a recurring concern?

Yes — Failure to provide face-to-face clinical assessment when clinically indicated.

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

Inadequate questionnaire on the person's medical history

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

Is this part of a recurring concern?

Yes — Incomplete clinical history-taking; Unreliable recording of patients' clinically relevant medical history.

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 notify the person's GP of prescribed drugs

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

Is this part of a recurring concern?

Yes — Unreliable communication of critical medication information to GPs.

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

Limited regulation of the prescribing company

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

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

Failure to prevent drug selection before prescriber contact

Wider context from the report

“1. There is no central tracking system or central database to record what each person has been prescribed and dispensed by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. ”

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

Publish guidance for pharmacist prescribers on sharing prescribing information with people’s prescribers and other care professionals.

Verbatim wording from the response

“We have also published ‘In practice: Guidance for pharmacist prescribers’, which set out the key areas we expect pharmacist prescribers to consider when applying the standards to their prescribing practice. The guidance states that prescribing information should be shared with the person’s prescriber, or others involved in their care, so the person receives safe and effective care.”

Source location

2021-0363-Response-from-GPC_Published
Page 3 · response
Published 4 November 2021

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

Enforce pharmacy standards by taking action against unsafe online medicine supply, including improvement notices and registration conditions.

Verbatim wording from the response

“We have taken enforcement action against the owners of online pharmacies who are supplying high risk, habit-forming medicines without appropriate steps being taken to check that the medicine being prescribed and dispensed is clinically appropriate for the patient.”

Source location

2021-0363-Response-from-GPC_Published
Page 3 · response
Published 4 November 2021

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

Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.

Verbatim wording from the response

“We have also worked with other healthcare organisations including regulators, royal colleges and faculties and have jointly-agreed High level principles for good practice in remote consultations and prescribing that set out the good practice of healthcare professionals when prescribing medication online. The ten principles, underpinned by existing expected standards and guidance, include that healthcare professionals are expected to:”

Source location

2021-0363-Response-from-GPC_Published
Page 3 · response
Published 4 November 2021

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

Inspect online providers’ management of medicines, prescriptions, consent, identity checks, information sharing, governance and staff safety training.

Verbatim wording from the response

“For those providers who fall within the CQC’s scope of regulation we inspect against the regulations using an inspection framework. All providers must comply with the regulations as set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (RAR 2014). The regulations that would be most relevant to any reviews around online providers, would include, but not be limited to, the following:”

Source location

2021-0363-Response-from-CQC_Published
Page 2 · response
Published 4 November 2021

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

Engage formally with the Department of Health and Social Care and submit legislative proposals to strengthen action against unsafe independent online providers.

Verbatim wording from the response

“Since January 2021 CQC has been in formal discussion with, and submitted proposals for legislative changes to, the Department of Health and Social Care (DHSC) to improve CQC’s ability to take action against independent providers of online primary care services that are putting people’s wellbeing and lives at risk.”

Source location

2021-0363-Response-from-CQC_Published
Page 4 · response
Published 4 November 2021

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

Work with regulatory partners and government organisations through cross-regulatory collaboration to improve oversight and mitigate online primary-care safety gaps.

Verbatim wording from the response

“We are also aware that our regulatory partners, including MHRA and the GPhC, share our concerns about the lack of regulatory oversight in this area.”

Source location

2021-0363-Response-from-CQC_Published
Page 4 · response
Published 4 November 2021

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

Publish guidance requiring providers to inform patients’ GPs about prescribed medications and assess safety when patients decline information sharing.

Verbatim wording from the response

“CQC has published guidance for providers¹. The guidance describes the expectations of providers to ensure a patient’s GP is informed of prescribed medications from their service. We also expect that should the patient decline to consent for the sharing”

Source location

2021-0363-Response-from-CQC_Published
Page 2 · response
Published 4 November 2021

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

Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.

Verbatim wording from the response

“I appreciate that the events giving rise to this inquest date from several years ago. In late 2019 we launched a call for evidence in relation to remote consultations and prescribing. This explored whether our existing guidance, which was last updated in 2013 and which applied at the time of Mr O’Connor’s death, had kept pace with changes in practice and the use of technology.”

Source location

2021-0363-Response-from-GMC_Published
Page 1 · response
Published 4 November 2021

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

Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.

Verbatim wording from the response

“Following this exercise, we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”

Source location

2021-0363-Response-from-GMC_Published
Page 1 · response
Published 4 November 2021

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

Work with healthcare regulators on digital healthcare provision.

Verbatim wording from the response

“The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.”

Source location

Response from DHSC
Page 2 · response
Published 4 November 2021

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

Review the UK legislative position on digital healthcare and identify regulatory gaps.

Verbatim wording from the response

“The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.”

Source location

Response from DHSC
Page 2 · response
Published 4 November 2021

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

A central system or database tracking prescribed and dispensed medicines, and the responsible individuals, is outside the remit.

Verbatim wording from the response

“We acknowledge your concern that there is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom. Although this specific aspect is outside of our remit, we do produce guidance, which is designed to support pharmacy owners and pharmacy professionals to meet our standards.”

Source location

2021-0363-Response-from-GPC_Published
Page 2 · response
Published 4 November 2021

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

Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.

Verbatim wording from the response

“Through our regulation of independent online primary medical services, CQC has identified gaps in the regulatory framework for independent online providers. We continue to have concerns about safety gaps, which generally align to those you have identified. We do however recognise there are benefits in the provision of online services, and for consultations and prescribing without the need for a face to face consultation where there are appropriate safeguards in place. These include history taking, engagement with the registered GP, and monitoring, as well as a risk assessing those medicines that are prescribed by a service. Our specific concerns are in the following areas:”

Source location

2021-0363-Response-from-CQC_Published
Page 3 · response
Published 4 November 2021

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

UK regulators have limited jurisdiction to act against harmful prescribing by providers or registered persons based outside the UK.

Verbatim wording from the response

“• generally, there is limited jurisdictional ability for UK regulators to take action in response to harmful prescribing by providers or registered persons based outside the UK.”

Source location

2021-0363-Response-from-CQC_Published
Page 3 · response
Published 4 November 2021

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

Existing legislation limits CQC action against unsafe independent online providers, requiring legislative changes to strengthen its regulatory powers.

Verbatim wording from the response

“We recognise the regulatory framework in this area needs to be updated to address emerging risks and to ensure independent online prescribers adhere to safe practice.”

Source location

2021-0363-Response-from-CQC_Published
Page 4 · response
Published 4 November 2021

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

Systems for accessing and sharing prescribing and dispensing information are outside the respondent’s remit.

Verbatim wording from the response

“Systems for accessing and sharing information about the prescribing and dispensing of medicines are outside the GMC’s remit. However, we strongly agree that effective systems are vital to ensuring safe and effective care.”

Source location

2021-0363-Response-from-GMC_Published
Page 2 · response
Published 4 November 2021

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 Department of Health and Social Care and Care Quality Commission are better placed to address regulation of health service organisations in England.

Verbatim wording from the response

“The GMC’s remit does not extend to organisations that provide health services. The Department of Health and Social Care and the Care Quality Commission may be better placed to comment on this issue as far as it relates to England.”

Source location

2021-0363-Response-from-GMC_Published
Page 4 · response
Published 4 November 2021

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

Regulation of organisations providing health services is outside the respondent’s remit.

Verbatim wording from the response

“The GMC’s remit does not extend to organisations that provide health services. The Department of Health and Social Care and the Care Quality Commission may be better placed to comment on this issue as far as it relates to England.”

Source location

2021-0363-Response-from-GMC_Published
Page 4 · response
Published 4 November 2021

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.5

  1. 1

    Refer pharmacy professionals whose prescribing or supply conduct falls below standards to the Fitness to Practise process.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
  2. 2

    Publish updated guidance for online pharmacies, including safeguards for remote medicine supply.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
  3. 3

    Publish pharmacy inspection reports to monitor compliance and promote safe, effective care.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
  4. 4

    Investigate online providers operating regulated activities without registration and take necessary enforcement action to bring them into regulation.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
  5. 5

    Review private prescribing of controlled drugs with healthcare regulators.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 4 November 2021.

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

  1. 1

    The medicines were supplied under an appropriate prescription, so no breach of Human Medicines Regulations requirements appears to have occurred.

    Stated by Department of Health and Social CareDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. 2

    The MHRA decides case by case whether particular treatment-service communications comply with medicines advertising regulations.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Refer pharmacy professionals whose prescribing or supply conduct falls below standards to the Fitness to Practise process.

Verbatim wording from the response

“We have also referred individual pharmacy professionals involved in both the prescribing and supply of medicines to our Fitness to Practise process where their conduct has fallen short of professional standards. If a pharmacy professional’s fitness to practise is found to be impaired, our Fitness to Practise Committee can impose a range of sanctions, including suspension or removal from the register.”

Source location

2021-0363-Response-from-GPC_Published
Page 4 · response
Published 4 November 2021

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

Publish updated guidance for online pharmacies, including safeguards for remote medicine supply.

Verbatim wording from the response

“We acknowledge your concern that there is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom. Although this specific aspect is outside of our remit, we do produce guidance, which is designed to support pharmacy owners and pharmacy professionals to meet our standards.”

Source location

2021-0363-Response-from-GPC_Published
Page 2 · response
Published 4 November 2021

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

Publish pharmacy inspection reports to monitor compliance and promote safe, effective care.

Verbatim wording from the response

“We seek assurance that pharmacy professionals and pharmacies continue to meet our standards. One of the methods we use to monitor compliance and establish if safe and effective care is being provided is by inspecting pharmacies. Since April 2019 we have published inspection reports on our inspection website here.”

Source location

2021-0363-Response-from-GPC_Published
Page 1 · response
Published 4 November 2021

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

Investigate online providers operating regulated activities without registration and take necessary enforcement action to bring them into regulation.

Verbatim wording from the response

“Where there are concerns a provider is operating carrying on a regulated activity falling within the scope of CQC registration without registration the CQC powers to investigate. Specifically, under section 10 of the Health and Social Care Act 2008 (section 10 HSCA 2008) it is an offence for persons to carry on regulated activities without being registered with the CQC to do so. Where it is brought to our attention that a provider may be offering a service that requires registration we do investigate and take such action as is necessary to bring them into regulation. CQC does investigate and has prosecuted the online provision of regulated activities without registration.”

Source location

2021-0363-Response-from-CQC_Published
Page 3 · response
Published 4 November 2021

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

Review private prescribing of controlled drugs with healthcare regulators.

Verbatim wording from the response

“The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK’s legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient’s GP before prescribing. There were also concerns about the absence of pharmacy records of medicines dispensed by other pharmacies. The Department and healthcare regulators are also working together to review prescribing by private prescribers in relation to controlled drugs.”

Source location

Response from DHSC
Page 2 · response
Published 4 November 2021

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 medicines were supplied under an appropriate prescription, so no breach of Human Medicines Regulations requirements appears to have occurred.

Verbatim wording from the response

“The MHRA has reviewed the supply of POMs to Mr O’Connor exchange information with the relevant regulators, CQC and GPhC. Enquiries revealed that the medicines were supplied in accordance with a prescription issued by an appropriate healthcare provider and consequently, no breach of regulatory requirements in the Human Medicines Regulations 2012 appear to have happened.”

Source location

Response from DHSC
Page 1 · response
Published 4 November 2021

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 MHRA decides case by case whether particular treatment-service communications comply with medicines advertising regulations.

Verbatim wording from the response

“Appendix 6 of the Blue Guide⁴ provides guidance for treatment service providers that outlines how to promote a service (and professional consultation) without breaking the law by promoting specific POMs to the public. If a complaint is received, the decision on whether a particular communication complies with the Regulations will be taken by the MHRA on a case-by-case basis, having regard to the circumstances of the particular case. Completed investigations are published on the Government’s website⁵.”

Source location

Response from DHSC
Page 3 · response
Published 4 November 2021

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