PFD report

Oliver James Billings · Prevention of Future Deaths report

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Issued 28 Nov 2024•Devon, Plymouth and Torbay

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
4

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
15

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 raised4

  1. Medication dispatch failing to allow mistakes to be noticed and remedied
    Part of recurring concern: Medication dispensing and dispatch errors not reliably detected
  2. Placing the onus on the patient to remedy prescription errors when the pharmacy cannot be contacted
  3. Submission of subsequent prescriptions despite knowledge that the first prescription was cancelled or to be cancelled
    Part of recurring concern: Failure to prevent duplicate or discontinued medication prescriptions
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.7

  1. Action

    Publish and make available the Repeat Prescribing Toolkit with guidance on reviewing and safely managing high-risk repeat medicines.

    Stated by Royal Pharmaceutical SocietyStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
  2. Action

    Continue monitoring inbound contact channels and performance to maintain prompt access for urgent contacts.

    Stated by Pharmacy2UStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
  3. Action

    Require prescription staff to email Pharmacy2U about prescription cancellations.

    Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.10

  1. Position

    The benefits of efficient, timely medicine supply outweigh the risks because prescribers should complete clinical appropriateness assessments before issuing prescriptions.

    Stated by Royal Pharmaceutical SocietyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

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

PFD Monitor interpretation

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. ”

Is this part of a recurring concern?

Yes — Medication dispensing and dispatch errors not reliably detected.

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. ”

Is this part of a recurring concern?

Yes — Failure to prevent duplicate or discontinued medication prescriptions.

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. ”

Is this part of a recurring concern?

Yes — Failure to prevent duplicate or discontinued medication prescriptions.

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 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
Page 2 · response
Published 2 December 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Continue 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
Page 3 · response
Published 2 December 2024

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

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
Page 3 · response
Published 2 December 2024

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

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
Page 4 · response
Published 2 December 2024

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

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
Page 3 · response
Published 2 December 2024

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

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
Page 3 · response
Published 2 December 2024

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

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
Page 2 · response
Published 2 December 2024

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 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
Page 3 · response
Published 2 December 2024

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

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
Page 3 · response
Published 2 December 2024

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

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
Page 2 · response
Published 2 December 2024

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 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
Page 3 · response
Published 2 December 2024

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 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
Page 2 · response
Published 2 December 2024

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 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
Page 1 · response
Published 2 December 2024

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

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
Page 3 · response
Published 2 December 2024

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 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
Page 1 · response
Published 2 December 2024

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 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
Page 1 · response
Published 2 December 2024

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 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
Page 3 · response
Published 2 December 2024

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.8

  1. 1

    Raise the identified safety issues with professional and representative pharmacy bodies to support advice and assistance to pharmacy professionals.

    Stated by Royal Pharmaceutical SocietyStated plannedThe respondent said that this action was planned when they made their response on 2 December 2024.
  2. 2

    Consider how to continue raising awareness of the identified safety issues through future communications and engagement with the pharmacy sector.

    Stated by Royal Pharmaceutical SocietyStated plannedThe respondent said that this action was planned when they made their response on 2 December 2024.
  3. 3

    Continue collaborating internally and with NHS and patient-safety groups to improve patient safety and share learning across organisations.

    Stated by Pharmacy2UStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2024.
  4. 4

    Produce a template to support prescription staff conducting cancellation risk assessments.

    Stated by Partners of Amicus Health GroupStated in progressThe respondent said that this action was in progress when they made their response on 2 December 2024.
  5. 5

    Give patients prescription codes and instruct them to ask the original nominated pharmacy to release prescriptions when changing pharmacy.

    Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
  6. 6

    Require prescription staff to conduct dynamic risk assessments before cancelling prescriptions.

    Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
  7. 7

    Require prescription staff to document all contact in clinical notes.

    Stated by Partners of Amicus Health GroupStated completedThe respondent said that this action was complete when they made their response on 2 December 2024.
  8. 8

    Flag high-risk patients prescribed potentially misusable medication for closer monitoring, regular review, risk assessment and shorter prescription durations.

    Stated by Partners of Amicus Health GroupStated plannedThe respondent said that this action was planned when they made their response on 2 December 2024.

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
Page 4 · response
Published 2 December 2024

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

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
Page 4 · response
Published 2 December 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Continue 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
Page 3 · response
Published 2 December 2024

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

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
Page 2 · response
Published 2 December 2024

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

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
Page 2 · response
Published 2 December 2024

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

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
Page 2 · response
Published 2 December 2024

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

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
Page 3 · response
Published 2 December 2024

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

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
Page 4 · response
Published 2 December 2024

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