PFD report

Simon HOCKENHULL · Prevention of Future Deaths report

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Issued 12 Jun 2025•Cheshire

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised2

  1. Inconsistent definition of a month for diabetic medication supplies
    Part of recurring concern: Unreliable diabetes care and management
  2. Lack of prescriber and dispenser awareness of medication supply duration issues
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.1

  1. Action

    Raise awareness of the report through communications and engagement with medicines and patient safety stakeholders.

    Stated by Royal Pharmaceutical SocietyStated plannedThe respondent said that this action was planned when they made their response on 19 June 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Calendar-month dispensing is impractical because manufacturer pack sizes, licensing requirements and risks of splitting packs constrain supply.

    Stated by Royal Pharmaceutical SocietyUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Inconsistent definition of a month for diabetic medication supplies

Wider context from the report

“In the course of this inquest, I have heard that some diabetic medications and devices have a life span of 14 days. When two are prescribed, they therefore amount to a 28 day supply. I have heard that this can cause problems as there are some pharmacists who interpret a 28 day supply as a “month”, and that it can therefore be challenging to obtain a further prescription within the same calendar month. For patients who already have a complex relationship with their medication and monitoring regime, the challenges this causes can mean that they then do not take their medication as consistently as they need to. For patients with a diagnosis of diabetes, this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis. At the heart of the issue seems to be that a “month” is being inconsistently defined. Sometimes it means 28 days, sometimes it is a calendar month. The RCGP RPS “Repeat Prescription Toolkit” (October 2024) does not seem to address this issue, so it may be that prescribers and dispensers are unaware of this issue. ”

Is this part of a recurring concern?

Yes — Unreliable diabetes care and management.

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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

Lack of prescriber and dispenser awareness of medication supply duration issues

Wider context from the report

“In the course of this inquest, I have heard that some diabetic medications and devices have a life span of 14 days. When two are prescribed, they therefore amount to a 28 day supply. I have heard that this can cause problems as there are some pharmacists who interpret a 28 day supply as a “month”, and that it can therefore be challenging to obtain a further prescription within the same calendar month. For patients who already have a complex relationship with their medication and monitoring regime, the challenges this causes can mean that they then do not take their medication as consistently as they need to. For patients with a diagnosis of diabetes, this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis. At the heart of the issue seems to be that a “month” is being inconsistently defined. Sometimes it means 28 days, sometimes it is a calendar month. The RCGP RPS “Repeat Prescription Toolkit” (October 2024) does not seem to address this issue, so it may be that prescribers and dispensers are unaware of this issue. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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 awareness of the report through communications and engagement with medicines and patient safety stakeholders.

Verbatim wording from the response

“Thank you for highlighting your concerns in this prevention of future death report. We will raise awareness of the report through our communications and engagement with other key medicines and patient safety stakeholders who play an important role in providing advice and support to the profession. It would also help if you and the family of Mr. Hockenhull were happy to give permission for us to see the full details of the case, in order to understand the details of what happened and if there is any further learning that could be shared with members of both the Royal Pharmaceutical Society and Royal College of General Practitioners.”

Source location

Response from Royal Pharmaceutical Society
Page 4 · response
Published 19 June 2025

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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

Calendar-month dispensing is impractical because manufacturer pack sizes, licensing requirements and risks of splitting packs constrain supply.

Verbatim wording from the response

“Calendar months in the year would be 28, 29 (leap year), 30 and 31 days, but this would be unworkable as previously mentioned, medication pack sizes are determined by the manufacturer and the licensing is based on the pack size submitted. Splitting some packs means the pharmacy would be supplying ‘off label’ which can bring separate issues around that. Again, these will vary depending on whether they are a “calendar” pack or a standard pack.”

Source location

Response from Royal Pharmaceutical Society
Page 4 · response
Published 19 June 2025

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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

Specific prescription-duration guidance was outside the Repeat Prescribing Toolkit’s agreed scope, which was not intended as a clinical guideline.

Verbatim wording from the response

“At the time of drafting the RCGP RPS Repeat Prescribing Toolkit, the Toolkit working group (made up of practicing GPs, Clinical Pharmacists, Patients, GP practice staff, NHS England policy leads and regulators), had been informed that NHS England may be exploring work on prescription duration and so it was agreed that specific guidance on prescription duration was out of scope for the toolkit. The toolkit was never intended to be a clinical guideline and so would not have addressed the specific issues that you have highlighted in this case. Annex A of the Toolkit (page 87) details what was within and outside of the scope of the Repeat Prescribing Toolkit.”

Source location

Response from Royal Pharmaceutical Society
Page 3 · response
Published 19 June 2025

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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

Medication-ordering risks are not usually linked to 28-day versus 30-day duration.

Verbatim wording from the response

“Whilst it is a risk that patients may forget to order their medication or order late or there is a delay in the prescription being issued from the GP practice or community pharmacy, it is not usually linked to the medication duration of 28 vs 30 days. It is worth noting that legislation permits the community pharmacist to issue an emergency supply of a patient’s regular medication following appropriate clinical checks.”

Source location

Response from Royal Pharmaceutical Society
Page 4 · response
Published 19 June 2025

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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