Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 15
Royal Pharmaceutical Society Publish and make available the Repeat Prescribing Toolkit with guidance on reviewing and safely managing high-risk repeat medicines.
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Royal Pharmaceutical Society Raise the identified safety issues with professional and representative pharmacy bodies to support advice and assistance to pharmacy professionals.
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Royal Pharmaceutical Society Consider how to continue raising awareness of the identified safety issues through future communications and engagement with the pharmacy sector.
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Pharmacy2U Continue monitoring inbound contact channels and performance to maintain prompt access for urgent contacts.
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Pharmacy2U Continue collaborating internally and with NHS and patient-safety groups to improve patient safety and share learning across organisations.
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Partners of Amicus Health Group Require prescription staff to email Pharmacy2U about prescription cancellations.
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Partners of Amicus Health Group Produce a template to support prescription staff conducting cancellation risk assessments.
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Partners of Amicus Health Group Give patients prescription codes and instruct them to ask the original nominated pharmacy to release prescriptions when changing pharmacy.
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Partners of Amicus Health Group Eliminate non-auditable messaging systems for clinical information in prescription management.
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Partners of Amicus Health Group Offer clinician-authorised bridging prescriptions of up to five days when suitable, avoiding cancellation and reissue.
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Partners of Amicus Health Group Require prescription staff to conduct dynamic risk assessments before cancelling prescriptions.
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Partners of Amicus Health Group Require prescription staff to document all contact in clinical notes.
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Partners of Amicus Health Group Flag high-risk patients prescribed potentially misusable medication for closer monitoring, regular review, risk assessment and shorter prescription durations.
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Partners of Amicus Health Group Monitor rejected electronic cancellation notifications daily and act on them when required.
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Partners of Amicus Health Group Require prescription cancellation to be treated as a last resort.
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× 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 Medication dispatch failing to allow mistakes to be noticed and remedied
Wider context from the report “(2) That the swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied .
” 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 Placing the onus on the patient to remedy prescription errors when the pharmacy cannot be contacted
Wider context from the report “(3) That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted .
” 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 Submission of subsequent prescriptions despite knowledge that the first prescription was cancelled or to be cancelled
Wider context from the report “(1) That a subsequent prescription was submitted in the knowledge that the first was cancelled or to be cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that prescription before the subsequent prescription was issued.
” 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 or inability to ascertain prescription status before issuing a subsequent prescription
Wider context from the report “(1) That a subsequent prescription was submitted in the knowledge that the first was cancelled or to be cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that prescription before the subsequent prescription was issued .
” Open source report
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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 Publish and make available the Repeat Prescribing Toolkit with guidance on reviewing and safely managing high-risk repeat medicines.
Verbatim wording from the response “High risk medicines and vulnerable patients
The recently published Royal College of General Practitioners and RPS Repeat Prescribing Toolkit¹, advises GPs to think carefully about their arrangements for repeat prescribing of medicines. Patients should be offered regular and careful review of their medicines and the decision to prescribe high-risk medicines should always be considered on an individual basis.” Source location Response from Royal Pharmaceutical Society
Open published response
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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 Raise the identified safety issues with professional and representative pharmacy bodies to support advice and assistance to pharmacy professionals.
Verbatim wording from the response “Thank you for highlighting your concerns in this prevention of future death report. We will consider how we can continue to raise awareness of these important issues through our future communications and engagement with the wider pharmacy sector. We will also raise these issues with our colleagues at the professional and representative bodies for pharmacy as they also play an important role in providing advice and support to the pharmacy professions.” Source location Response from Royal Pharmaceutical Society
Open published response
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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 Consider how to continue raising awareness of the identified safety issues through future communications and engagement with the pharmacy sector.
Verbatim wording from the response “Thank you for highlighting your concerns in this prevention of future death report. We will consider how we can continue to raise awareness of these important issues through our future communications and engagement with the wider pharmacy sector. We will also raise these issues with our colleagues at the professional and representative bodies for pharmacy as they also play an important role in providing advice and support to the pharmacy professions.” Source location Response from Royal Pharmaceutical Society
Open published response
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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 Continue monitoring inbound contact channels and performance to maintain prompt access for urgent contacts.
Verbatim wording from the response “I have no evidence of contact from the surgery or the patient in relation to this prescription. The PFD report states that a matter of concern is “That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted”. I consider that it is incorrect to state that we “could not be contacted”, as we at all times remained available to be contacted. As a matter of good business practice, we continually review our inbound contact capacity and performance to ensure that anyone who wants to contact us can do so quickly and easily, and we will always continue to monitor this.” Source location Response from Pharmacy2U
Open published response
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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 Continue collaborating internally and with NHS and patient-safety groups to improve patient safety and share learning across organisations.
Verbatim wording from the response “3. I have also discussed this case with our senior clinical management team as part of our clinical review process and we will continue to work internally and with our healthcare colleagues in other parts of the NHS, as well as with groups such as the Community Pharmacy Patient Safety Group, to continue to improve patient safety and share learnings across organisations.” Source location Response from Pharmacy2U
Open published response
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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 Require prescription staff to email Pharmacy2U about prescription cancellations.
Verbatim wording from the response “• Asked all prescriptions staff to email Pharmacy2U to communicate cancellations. This is under their direction as their phonelines are not well manned and/or in high demand – They state in their message that they prefer email. A call can take more than an hour to be answered, and it is not sustainable for us to use our limited resource calling them, given their poor answering capacity.” Source location Response from Amicus Health
Open published response
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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 Produce a template to support prescription staff conducting cancellation risk assessments.
Verbatim wording from the response “• Ensured that the prescription team, if cancelling prescriptions are conducting a dynamic risk assessment to ascertain why this cancellation is required. As a further development a template is being produced to support their thinking on this.” Source location Response from Amicus Health
Open published response
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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 Give patients prescription codes and instruct them to ask the original nominated pharmacy to release prescriptions when changing pharmacy.
Verbatim wording from the response “• Sought assurance that patients, when requesting a change of pharmacy after prescription issue, are given a prescription code and asked to contact the original nominated pharmacy to release back to the spine. Informing them they can then take that code to any pharmacy to prescribe. We do this as” Source location Response from Amicus Health
Open published response
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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 Eliminate non-auditable messaging systems for clinical information in prescription management.
Verbatim wording from the response “Improved Communication Protocols: We have eliminated the use of non-auditable messaging systems (e.g., screen messages) for clinical information to ensure transparency and accountability in prescription management as we believe that this method was used for communication between Prescription Clerk B and the GP who issued the second prescription.” Source location Response from Amicus Health
Open published response
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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 Offer clinician-authorised bridging prescriptions of up to five days when suitable, avoiding cancellation and reissue.
Verbatim wording from the response “• Provided an alternative to cancellation and reissue in cases where the patient is worried about a delay from the pharmacy. Namely asking clinicians to provide a ‘bridging prescription’ to cover the days missing. This reduces the amount of medication being requested and therefore the risk. It also avoids cancelling a prescription. It should be noted that this does however have an additional cost to the patient and the NHS that would be avoided if we could easily cancel and reissue.” Source location Response from Amicus Health
Open published response
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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 Require prescription staff to conduct dynamic risk assessments before cancelling prescriptions.
Verbatim wording from the response “• Ensured that the prescription team, if cancelling prescriptions are conducting a dynamic risk assessment to ascertain why this cancellation is required. As a further development a template is being produced to support their thinking on this.” Source location Response from Amicus Health
Open published response
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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 Require prescription staff to document all contact in clinical notes.
Verbatim wording from the response “• Ensured all prescription staff are aware that they need to make certain all contact is documented in the notes.” Source location Response from Amicus Health
Open published response
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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 Flag high-risk patients prescribed potentially misusable medication for closer monitoring, regular review, risk assessment and shorter prescription durations.
Verbatim wording from the response “Risk Assessments for High-Risk Medications: Patients identified as high risk of suicide and prescribed medications such as will be flagged for closer monitoring. This includes regular reviews, risk assessments, and ensuring prescriptions are limited to shorter durations to minimise potential misuse.” Source location Response from Amicus Health
Open published response
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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 Monitor rejected electronic cancellation notifications daily and act on them when required.
Verbatim wording from the response “• Reviewed processes related to rejected prescription cancellation notifications within our clinical system. This is an alert that will tell us within our clinical system if there has been a cancellation request that has been rejected due to already being downloaded by the pharmacy. To ensure that these are monitored, and acted upon when required, a member of the prescriptions team is assigned to review this each day.” Source location Response from Amicus Health
Open published response
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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 Require prescription cancellation to be treated as a last resort.
Verbatim wording from the response “That said, we are committed to taking the steps we can, to prevent any future tragedies and we believe we have taken all measures that are within our control. We have taken the following action to safeguard against any future duplication of prescriptions:” Source location Response from Amicus Health
Open published response
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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 benefits of efficient, timely medicine supply outweigh the risks because prescribers should complete clinical appropriateness assessments before issuing prescriptions.
Verbatim wording from the response “Dispensing and supply of medicines from a community pharmacy
The coroner’s report refers to the ‘swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied’. It is worth noting that under the NHS Community Pharmacy Contractual Framework Essential Service – Dispensing, there is a contractual obligation for community pharmacies in England to dispense medication for patients with reasonable promptness. Medicines optimisation is about ensuring that the right patient receives the right medicine at the right time. All assessments of the clinical appropriateness of a medication by a prescriber should be complete before issuing the prescription, therefore the subsequent benefits of a safe and timely supply of medicines would outweigh risks of supplying medicines efficiently.” Source location Response from Royal Pharmaceutical Society
Open published response
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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 Reminding prescribers about cancellation guidance may be a matter for the professional leadership body for GPs.
Verbatim wording from the response “1. I consider that there may be a need for all prescribers to be reminded of the applicable guidance highlighted above and the importance of making direct contact with a pharmacy if they wish to cancel an electronic NHS prescription that has already been issued and downloaded by a pharmacy, and to follow the instructions in their clinical system when it alerts them that the electronic cancellation was ineffective. This may be a matter for the professional leadership body for GPs.” Source location Response from Pharmacy2U
Open published response
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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 Without direct contact from the prescriber, the pharmacy could not reasonably establish that an already downloaded prescription was intended to be cancelled.
Verbatim wording from the response “In the absence of direct contact, as described above, regrettably I consider that there are no reasonable steps which we could have taken to have established that the prescriber had attempted a cancellation of the prescription on the spine after we had downloaded it.” Source location Response from Pharmacy2U
Open published response
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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 pharmacy disputes that it could not be contacted, stating it remained available and monitored its inbound contact capacity and performance.
Verbatim wording from the response “I have no evidence of contact from the surgery or the patient in relation to this prescription. The PFD report states that a matter of concern is “That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted”. I consider that it is incorrect to state that we “could not be contacted”, as we at all times remained available to be contacted. As a matter of good business practice, we continually review our inbound contact capacity and performance to ensure that anyone who wants to contact us can do so quickly and easily, and we will always continue to monitor this.” Source location Response from Pharmacy2U
Open published response
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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 dispensing processes and required reasonable promptness are considered sufficient; planned delays to allow post-prescribing checks would be unsafe and disproportionate.
Verbatim wording from the response “The NHS Community Pharmacy Contractual Framework requires that NHS medicines and appliances are dispensed by registered pharmacies for patients on demand with “reasonable promptness” (Exhibit 1). I consider that it would be neither safe nor proportionate to introduce planned delays into pharmacy processes to allow a prescriber extra time to identify any post-prescribing concerns over and above those delays which are a natural part of a pharmacy’s existing processes.” Source location Response from Pharmacy2U
Open published response
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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 existing policy of asking patients to arrange pharmacy changes directly was considered sufficient where the request is patient-initiated.
Verbatim wording from the response “Our internal review identified that initially the action taken was correct in that when Prescription Clerk A was asked by Mr Billings to change where the prescription was being sent, she informed him that he would need to contact Pharmacy2u to ask them to release the prescription so that his preferred pharmacy could dispense the prescription instead. This is in line with our policy and ensures that there is not a duplication of prescription. The process to change a pharmacy once the prescription has been sent involves contacting pharmacies directly and at present there is not a direct route for practices to easily do this. Where this change is at patient request, rather than as a result of an error, we put the onus back on the patient to arrange this.” Source location Response from Amicus Health
Open published response
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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 Changing online pharmacies’ rapid prescription dispatch and automatic drawdown is outside the practice’s scope.
Verbatim wording from the response “As noted above we understand that rapid dispatch of medications can limit the window for rectifying errors. Unfortunately, it is not within our scope to change this. We would encourage Pharmacy2U and other online pharmacies to explore the feasibility of implementing a more accessible cancellation process. We feel that the automatic drawdown of prescriptions, which subsequently prevents cancellation should be reviewed to reduce the additional administrative burden on general practice and reduce cost to the NHS in fees, because of unnecessary medication dispensing.” Source location Response from Amicus Health
Open published response
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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 initial advice to contact Pharmacy2U was considered correct, and no error had occurred at that interaction.
Verbatim wording from the response “Our internal review identified that initially the action taken was correct in that when Prescription Clerk A was asked by Mr Billings to change where the prescription was being sent, she informed him that he would need to contact Pharmacy2u to ask them to release the prescription so that his preferred pharmacy could dispense the prescription instead. This is in line with our policy and ensures that there is not a duplication of prescription. The process to change a pharmacy once the prescription has been sent involves contacting pharmacies directly and at present there is not a direct route for practices to easily do this. Where this change is at patient request, rather than as a result of an error, we put the onus back on the patient to arrange this.” Source location Response from Amicus Health
Open published response
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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 practice cannot easily cancel prescriptions after pharmacy download because cancellation routes and pharmacy communications are not sufficiently accessible.
Verbatim wording from the response “Our internal review identified that initially the action taken was correct in that when Prescription Clerk A was asked by Mr Billings to change where the prescription was being sent, she informed him that he would need to contact Pharmacy2u to ask them to release the prescription so that his preferred pharmacy could dispense the prescription instead. This is in line with our policy and ensures that there is not a duplication of prescription. The process to change a pharmacy once the prescription has been sent involves contacting pharmacies directly and at present there is not a direct route for practices to easily do this. Where this change is at patient request, rather than as a result of an error, we put the onus back on the patient to arrange this.” Source location Response from Amicus Health
Open published response
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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 pharmacies and relevant regulatory bodies are asked to review and improve prescription cancellation and communication processes.
Verbatim wording from the response “As noted above we understand that rapid dispatch of medications can limit the window for rectifying errors. Unfortunately, it is not within our scope to change this. We would encourage Pharmacy2U and other online pharmacies to explore the feasibility of implementing a more accessible cancellation process. We feel that the automatic drawdown of prescriptions, which subsequently prevents cancellation should be reviewed to reduce the additional administrative burden on general practice and reduce cost to the NHS in fees, because of unnecessary medication dispensing.” Source location Response from Amicus Health
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