PFD report

Claire COPELAND · Prevention of Future Deaths report

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Issued 8 Mar 2022•County Durham and Darlington

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
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
11

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. Lack of a mechanism to remedy failed delivery
    Part of recurring concern: Unreliable prescription collection and delivery arrangements
  2. Lack of an effective mechanism for immediate detection of failed delivery
    Part of recurring concern: Unreliable prescription collection and delivery arrangements
  3. Failure to witness or confirm delivery
    Part of recurring concern: Unreliable prescription collection and delivery arrangements
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.8

  1. Action

    Agree contingency plans for failed deliveries and escalate unresolved issues to the Area Manager and Clinical Lead.

    Stated by WaythroughStated plannedThe respondent said that this action was planned when they made their response on 10 March 2022.
  2. Action

    Require failed delivery attempts to be reported immediately by telephone to a nominated on-site manager using prearranged contact details.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 10 March 2022.
  3. Action

    Record failed prescription deliveries in the incident system, notify relevant staff, review incidents and identify learning to prevent recurrence.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 10 March 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

    Electronic transfer of controlled-drug instalment prescriptions is unavailable nationally, so physical prescriptions remain unavoidable until functionality is developed.

    Stated by WaythroughUnable 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

Lack of a mechanism to remedy failed delivery

Wider context from the report

“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”

Is this part of a recurring concern?

Yes — Unreliable prescription collection and delivery arrangements.

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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 an effective mechanism for immediate detection of failed delivery

Wider context from the report

“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”

Is this part of a recurring concern?

Yes — Unreliable prescription collection and delivery arrangements.

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 witness or confirm delivery

Wider context from the report

“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”

Is this part of a recurring concern?

Yes — Unreliable prescription collection and delivery arrangements.

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

Reliance upon delivery of a physical prescription document

Wider context from the report

“Arrangements to which you are a party: • rely upon delivery of a physical prescription document; • allow that delivery be neither witnessed nor confirmed; • lack effective mechanism immediately to detect failed delivery; and • lack mechanism to remedy failed delivery; and thereby presents danger to life in that it is capable of causing discontinuity of important medical treatment. ”

Is this part of a recurring concern?

Yes — Unreliable prescription collection and delivery arrangements.

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

Agree contingency plans for failed deliveries and escalate unresolved issues to the Area Manager and Clinical Lead.

Verbatim wording from the response

“During the telephone contact between the team member attempting to deliver the prescription and nominated manager a contingency plan will be agreed. This plan will take into account the individual circumstances of the delivery including known pharmacy availability and the timescale requirement of dispensing from the prescription. Continuity of care for the service user and safe prescription management will be equally paramount in agreeing a course of action. If an effective contingency plan cannot be immediately agreed, the issue will be escalated to the service Area Manager and Clinical Lead for further guidance and resolution.”

Source location

Response from HumanKind
Page 2 · response
Published 10 March 2022

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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 failed delivery attempts to be reported immediately by telephone to a nominated on-site manager using prearranged contact details.

Verbatim wording from the response

“The service’s prescription delivery standard operating procedure states that should it not be possible to directly deliver and confirm delivery of a prescription, the team member should return to their vehicle and make telephone contact with a nominated manager who is on-site within the service base.”

Source location

Response from HumanKind
Page 2 · response
Published 10 March 2022

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

Record failed prescription deliveries in the incident system, notify relevant staff, review incidents and identify learning to prevent recurrence.

Verbatim wording from the response

“Any failed delivery attempt of a prescription is recorded as an incident within Humankind’s incident management system. This system notifies all relevant managers and team members of the incident, creates a review process and supports identification of learning to prevent further occurrences.”

Source location

Response from HumanKind
Page 2 · response
Published 10 March 2022

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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

Provide Saturday morning service availability to remedy unresolved Friday prescription deliveries and maintain weekend provision.

Verbatim wording from the response

“For any failed deliveries on a Friday that cannot be resolved on that day, the service is available on a Saturday morning, enabling an opportunity to remedy delivery and ensure provision for the weekend.”

Source location

Response from HumanKind
Page 2 · response
Published 10 March 2022

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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 deliveries to pharmacies to be made directly to staff, with recipient details, signature, returned paperwork and management-system records.

Verbatim wording from the response

“A comprehensive standard operating procedure for all team members delivering prescriptions to pharmacies has been implemented. This includes the mandatory requirement for prescriptions to be handed directly to a member of the pharmacy staff team, obtaining details of the person taking receipt and a signature from that person to confirm delivery. Completed paperwork is returned to the service base and stored for reference and also included within the service’s management information system.”

Source location

Response from HumanKind
Page 1 · response
Published 10 March 2022

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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

Escalate the lack of electronic FP10 MDA prescription functionality through relevant national and professional networks.

Verbatim wording from the response

“Further to this, at this time there is no functionality for the electronic transfer of FP10 MDA blue instalment prescriptions. This is a national issue and not specific to Humankind/Spectrum/County Durham Drug and Alcohol Recovery Service. Humankind have continued to escalate this issue, for example with Controlled Drugs Local Intelligence Networks and the Office of Health Inequalities and Disparities, especially during the COVID-19 pandemic where the ongoing need for this to be resolved became especially pertinent.”

Source location

Response from HumanKind
Page 1 · response
Published 10 March 2022

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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

Encourage treatment clinics to contact pharmacies and confirm receipt of posted FP10MDA forms.

Verbatim wording from the response

“However, Boots will encourage clinics to contact the pharmacies to confirm receipt where FP10MDA forms are posted to try and avoid the risk of future failed deliveries.”

Source location

Response from Boots UK
Page 2 · response
Published 10 March 2022

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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

Remind pharmacists to direct patients to local hospital Accident & Emergency teams when FP10MDA problems arise outside clinic hours.

Verbatim wording from the response

“Boots will remind its pharmacists that, where any problems regarding FP10MDA forms are reported outside of clinic hours, patients must be directed to the Accident & Emergency team at a local hospital, so that an appropriate prescriber can review the patient’s circumstances and consider providing an interim prescription, pending the clinic reopening.”

Source location

Response from Boots UK
Page 2 · response
Published 10 March 2022

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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

Electronic transfer of controlled-drug instalment prescriptions is unavailable nationally, so physical prescriptions remain unavoidable until functionality is developed.

Verbatim wording from the response

“Unfortunately, the County Durham Drug and Alcohol Recovery Service, along with all other community drug and alcohol services, must rely on paper prescriptions as pharmacies cannot legally use faxed copies of prescriptions to dispense from for controlled drugs, including buprenorphine.”

Source location

Response from HumanKind
Page 1 · response
Published 10 March 2022

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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

Outside clinic hours, pharmacists have no route to contact a prescriber familiar with the patient and request an urgent replacement prescription.

Verbatim wording from the response

“Community pharmacies typically provide dispensing services, including the dispensing of methadone for the treatment of addiction, for more hours each week than the clinics are available. When a problem with an FP10MDA form (including a missing prescription) is detected outside of clinic hours, there is no route for a pharmacist to contact one of its prescribers (who will be familiar with the patient’s medical history) and request an urgent replacement prescription.”

Source location

Response from Boots UK
Page 2 · response
Published 10 March 2022

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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

Electronic prescribing is unavailable for FP10MDA instalment prescriptions, leaving paper forms as the only legal mechanism.

Verbatim wording from the response

“The prescription in question for Ms Copeland was for methadone oral solution, a Schedule 2 Controlled Drug, the supply of which from a community pharmacy is governed by the Human Medicines Regulations 2012 and the Misuse of Drugs Regulations 2001 (as amended).”

Source location

Response from Boots UK
Page 1 · response
Published 10 March 2022

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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

Pharmacies cannot detect failed deliveries because patients may choose any community pharmacy for dispensing.

Verbatim wording from the response

“Patients have a free choice regarding the community pharmacy that they attend for the dispensing of their prescriptions. It is therefore not possible for pharmacies to detect any failed deliveries.”

Source location

Response from Boots UK
Page 2 · response
Published 10 March 2022

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

Pharmacies cannot supply Schedule 2 medication after failed FP10MDA delivery without a replacement paper prescription, including through emergency supply.

Verbatim wording from the response

“As noted under (1) above, the supply of a Schedule 2 Controlled Drug from community pharmacies is governed by the Human Medicines Regulations 2012 and the Misuse of Drugs Regulations 2001 (as amended). A pharmacy is not permitted in law to provide medication (including an emergency supply), where there is a failed delivery of an FP10MDA form, unless a replacement paper FP10MDA form is provided.”

Source location

Response from Boots UK
Page 2 · response
Published 10 March 2022

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

Treatment clinics or service commissioners, rather than Boots, would need to require witnessed delivery and monitor failed prescription deliveries.

Verbatim wording from the response

“This would be within the power of individual treatment clinics or the service commissioners, who could require all clinics posting FP10MDA forms to use recorded in-person delivery and also put in place an administrative system to monitor for failed deliveries of prescription forms.”

Source location

Response from Boots UK
Page 2 · response
Published 10 March 2022

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.3

  1. 1

    Restrict prescription delivery to authorised team members who have confirmed understanding of the delivery instructions.

    Stated by WaythroughStated completedThe respondent said that this action was complete when they made their response on 10 March 2022.
  2. 2

    Liaise with the Community Pharmacy Patient Safety Group Chair to disseminate anonymised case-study insights.

    Stated by Boots UK LimitedStated completedThe respondent said that this action was complete when they made their response on 10 March 2022.
  3. 3

    Develop a dedicated Controlled Drug Stewardship resource supporting compassionate, person-centred care in controlled-drug supply.

    Stated by Boots UK LimitedStatus unclearThe respondent did not make the status of this action clear when they made their response on 10 March 2022.

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

Restrict prescription delivery to authorised team members who have confirmed understanding of the delivery instructions.

Verbatim wording from the response

“Service managers ensure that only team members authorised to do so deliver prescriptions. The authorisation process includes written confirmation that the team member is aware of, and understands, the instructions for prescription delivery.”

Source location

Response from HumanKind
Page 1 · response
Published 10 March 2022

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

Liaise with the Community Pharmacy Patient Safety Group Chair to disseminate anonymised case-study insights.

Verbatim wording from the response

“I hope this letter provides the necessary assurance that Boots has duly noted the gravitas of the concerns raised during the course of the inquest into Ms Copeland’s death, reflected on the circumstances of this sad case and shared its insights appropriately. As a founder member of the (external) Community Pharmacy Patient Safety Group, Boots has liaised with its Chair so that further dissemination of our insights from this case can be effected, using an anonymised case study format, at its next meeting.”

Source location

Response from Boots UK
Page 3 · response
Published 10 March 2022

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

Develop a dedicated Controlled Drug Stewardship resource supporting compassionate, person-centred care in controlled-drug supply.

Verbatim wording from the response

“Ms Copeland’s clinic (Human Kind) was closed on Saturday 12 June 2021 when she arrived at the Boots pharmacy in Consett, expecting to collect her medication. On reflection, the pharmacist has considered whether direct contact with the Accident & Emergency team at the local hospital (to explain the unique circumstances and ascertain whether they would review the patient’s prescription needs) could have addressed the lack of other ‘out-of-hours’ support for Ms Copeland. As a Company, we have taken the opportunity to renew our focus on Controlled Drug Stewardship, with the development of a dedicated resource to support all our pharmacy teams’ understanding of the need for compassionate, person-centred care when managing supplies of Controlled Drug medication.”

Source location

Response from Boots UK
Page 2 · response
Published 10 March 2022

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