PFD report

Steven Thomas Fone · Prevention of Future Deaths report

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Issued 27 Mar 2017•Manchester South

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
1

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

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Concerns and recipient responses

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Concerns raised1

  1. Failure to control and document consent for interchangeable collection of prescriptions
    Part of recurring concern: Inadequate controls on supplying medicinal products to unauthorised customers
Responses linked to these concerns

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No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 control and document consent for interchangeable collection of prescriptions

Wider context from the report

“During the course of evidence at the Inquest I was informed that Adams Pharmacy permitted three separate customers in receipt of prescriptions to interchangeably collect each other's prescriptions. No documentation was before the court to confirm whether consent had been given by any customer. I would like to know whether this practice is approved of by the relevant regulator of pharmacies. It seems to me this practice could be open to abuse and facilitate stock-piling leading to an increased risk of harm or death to those prescribed medicines which have the propensity to be fatal if taken outside the recommended guidance. ”

Is this part of a recurring concern?

Yes — Inadequate controls on supplying medicinal products to unauthorised customers.

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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