PFD report

Sewa Kaur Chaddha · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 2 Jun 2024•Berkshire

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.

View original report
Concerns
2

Raised in this report

Recipients
8

Named on the report

Responses found
8

Of 8 recipients

Stated actions
32

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address
    Part of recurring concern: Failure to ensure medication packaging is clearly distinguishablePart of recurring concern: Unreliable packaging and identification of dispensed medication
  2. Lack of disseminated guidance for pharmacists issuing medication to patients with cognitive impairments
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.12

  1. Action

    Inform NHS England’s pharmacy team about the case and request consideration of changes to the Community Pharmacy Contractual Framework.

    Stated by NHS Frimley Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  2. Action

    Publish information for pharmacy professionals on supporting patients with dementia and their carers when supplying and managing medicines.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  3. Action

    Produce supporting equality guidance to help pharmacy owners and professionals provide person-centred care for patients with different needs, including cognitive impairment.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.11

  1. Position

    Different dosette or label colours are not currently available because legal labelling requirements limit community pharmacy options.

    Stated by NHS Frimley Integrated Care BoardUnable 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

Failure to adequately differentiate dosset boxes for elderly or cognitively impaired patients living at the same address

Wider context from the report

“1) The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis. (2) Both patients were elderly and had cognitive impairment. (3) The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name. (4) Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days. (5) Evidence was given at the inquest that there was no guidance or policy in place for Pharmacists to follow when issuing medication to patients with cognitive impairments, or if there was, it was not well disseminated among the pharmacist population. (6) Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address. ”

Is this part of a recurring concern?

Yes — Failure to ensure medication packaging is clearly distinguishable; Unreliable packaging and identification of dispensed medication.

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

Lack of disseminated guidance for pharmacists issuing medication to patients with cognitive impairments

Wider context from the report

“1) The medications were provided to the couple by the local pharmacy, then known as Lloyds Pharmacy, in separate dosset boxes. Mrs Chaddha’s medications were provided on a weekly basis. Mr Chaddha’s were provided on a monthly basis. (2) Both patients were elderly and had cognitive impairment. (3) The two patients’ dosset boxes were identical to each other except for a small pharmacist’s label with small type with the relevant patient’s name. (4) Mrs Chaddha used one of Mr Chaddha’s dosset boxes, rather than her own, for several days. (5) Evidence was given at the inquest that there was no guidance or policy in place for Pharmacists to follow when issuing medication to patients with cognitive impairments, or if there was, it was not well disseminated among the pharmacist population. (6) Evidence was given at the inquest that dosset boxes of different colours or labels with different colours were not routinely given to elderly or cognitively impaired patients living at the same address. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Inform NHS England’s pharmacy team about the case and request consideration of changes to the Community Pharmacy Contractual Framework.

Verbatim wording from the response

“We recognise that guidance documents alone are often insufficient. Lasting and effective change requires embedding these guidelines within contracts and regulations. We will therefore inform NHS England’s pharmacy team of this case and request that they consider potential changes to the Community Pharmacy Contractual Framework.”

Source location

Response from Berkshire Integrated Care Board
Page 3 · response
Published 15 October 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

Publish information for pharmacy professionals on supporting patients with dementia and their carers when supplying and managing medicines.

Verbatim wording from the response

“care that takes account of the diverse needs and cultural differences in the communities they serve. To share an example, we recently published information to the pharmacy profession about providing services to patients and their carers living with dementia, as an umbrella term for a range of over 200 subtypes of progressive conditions that affect the brain and a person’s ability to remember, think and speak. Through this communication, we highlighted the following points about supporting patients who may need assistance with their medicines:”

Source location

Response from General Pharmaceutical Council
Page 2 · response
Published 15 October 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 supporting equality guidance to help pharmacy owners and professionals provide person-centred care for patients with different needs, including cognitive impairment.

Verbatim wording from the response

“We also produce supporting guidance to help pharmacy owners and pharmacy professionals to put the standards into practice. This includes our equality guidance, which is designed to help pharmacy owners improve the experience and healthcare outcomes of patients and members of the public using their pharmacy’s services. The guidance sets out examples taken from our GPhC Knowledge Hub and our pharmacy inspections work about how pharmacy teams are supporting patients with different needs, including cognitive and visual impairment.”

Source location

Response from General Pharmaceutical Council
Page 1 · response
Published 15 October 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

Advocate for Royal Pharmaceutical Society information and guidance to become available to non-members.

Verbatim wording from the response

“Suggested actions in response to the matters of concern”

Source location

Response from Specialist Pharmacy Service
Page 3 · response
Published 15 October 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 adding wording recommending clear medicine labelling to distinguish household members, particularly those who are elderly or cognitively impaired.

Verbatim wording from the response

“13. The SPS will consider including additional wording to that in Annex 1, to recommend that medicines are clearly labelled for differentiation between household members, particularly for patients who are elderly and/or have cognitive impairment.”

Source location

Response from Specialist Pharmacy Service
Page 3 · response
Published 15 October 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

Review existing guidance and consider refinements for supporting patients with cognitive impairments.

Verbatim wording from the response

“The NPA supports its Member pharmacies with advice, guidance and resources to help them to provide person-centred care in accordance with the pharmacy regulator’s, the General Pharmaceutical Council’s, standards. Our support includes guidance on equality, diversity and inclusion, monitored dosage systems (dosette boxes) and reasonable adjustments, including guidance on conducting patient assessments to help pharmacies determine how best to support patients with different needs including visual impairment, confusion and dementia, and signposting to information and support from the General Pharmaceutical Council.”

Source location

Response from National Pharmacy Association
Page 1 · response
Published 15 October 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 ways to further raise awareness of cognitive-impairment medication safety among member pharmacies.

Verbatim wording from the response

“We will review our existing guidance and consider how we can refine it. We will consider how we can continue to further raise awareness of this issue with our Member pharmacies. In our role of Medication Safety Officer (MSO) for independent pharmacies, and a member of the sector-wide Patient Safety Group (which also includes representatives of corporate pharmacies), we will also raise this matter with the Group so that it can be considered by all MSOs across community pharmacy.”

Source location

Response from National Pharmacy Association
Page 1 · response
Published 15 October 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

Raise the risk of confusing multi-compartment aids in one household with the Royal Pharmaceutical Society and request consideration of additional guidance or information.

Verbatim wording from the response

“Our action. We will bring this concern – the need for different MCAs in one household to be very clearly identified in such a way that those with cognitive impairment remain safe and take their medicines - to the RPS and the Community Pharmacy Patient Safety Group (CPPSG), and ask each to consider additional guidance and/or information to be made available to pharmacies and pharmacists. We will also make community pharmacy owners we represent aware of this concern or specific risk, initially ourselves and subsequently if the RPS or CPPSG issues any advice or reports. We will seek to take these actions in the autumn of this year.”

Source location

Response from Community Pharmacy England
Page 2 · response
Published 15 October 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

Raise the risk of confusing multi-compartment aids in one household with the Community Pharmacy Patient Safety Group and request consideration of additional guidance or information.

Verbatim wording from the response

“Our action. We will bring this concern – the need for different MCAs in one household to be very clearly identified in such a way that those with cognitive impairment remain safe and take their medicines - to the RPS and the Community Pharmacy Patient Safety Group (CPPSG), and ask each to consider additional guidance and/or information to be made available to pharmacies and pharmacists. We will also make community pharmacy owners we represent aware of this concern or specific risk, initially ourselves and subsequently if the RPS or CPPSG issues any advice or reports. We will seek to take these actions in the autumn of this year.”

Source location

Response from Community Pharmacy England
Page 2 · response
Published 15 October 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

Inform represented community pharmacy owners about the risk of confusing multi-compartment aids in one household.

Verbatim wording from the response

“Our action. We will bring this concern – the need for different MCAs in one household to be very clearly identified in such a way that those with cognitive impairment remain safe and take their medicines - to the RPS and the Community Pharmacy Patient Safety Group (CPPSG), and ask each to consider additional guidance and/or information to be made available to pharmacies and pharmacists. We will also make community pharmacy owners we represent aware of this concern or specific risk, initially ourselves and subsequently if the RPS or CPPSG issues any advice or reports. We will seek to take these actions in the autumn of this year.”

Source location

Response from Community Pharmacy England
Page 2 · response
Published 15 October 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

Double-check each tray with the patient after removing it from packaging.

Verbatim wording from the response

“Upon finding out we have amended our processes further to ensure that this does not happen again. We operate strict standard operating procedures which involve each tray being removed from packaging and double checked again with the patient.”

Source location

Response from Slough Pharmacy
Page 1 · response
Published 15 October 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

Provide differently branded trays with distinct packaging to households where multiple people use trays.

Verbatim wording from the response

“We have further added to our SOPs, and now provide a different brand of trays with totally different packaging to any households that involve more than one person with trays.”

Source location

Response from Slough Pharmacy
Page 1 · response
Published 15 October 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

Different dosette or label colours are not currently available because legal labelling requirements limit community pharmacy options.

Verbatim wording from the response

“Dosette boxes are not always suitable or the only solution for supporting a patient in taking their medication. Although various types of dosette boxes are available for purchase by the public, there are only a limited number used within community pharmacy due to the requirement that dosettes used must enable fulfilment of the legal labelling requirements. These are not currently available in different colours or label colours.”

Source location

Response from Berkshire Integrated Care Board
Page 3 · response
Published 15 October 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

Community pharmacies are independent contractors under a national framework, limiting the ICB’s direct influence over their processes.

Verbatim wording from the response

“I am replying as the Chief Pharmacist for NHS Frimley, responsible for medicines optimisation and pharmacy across our system. While we recognise our duty to address the concerns raised, it is important to note that community pharmacies and other healthcare professionals operate as independent contractors under a national framework or contract, limiting our direct influence over their processes.”

Source location

Response from Berkshire Integrated Care Board
Page 1 · response
Published 15 October 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

Concerns about pharmacists’ dispensing actions should be addressed to the General Pharmaceutical Council, the pharmacy and pharmacist regulator.

Verbatim wording from the response

“However, the matters of concern relate to actions taken by a pharmacist during the dispensing process, and we believe therefore they are better addressed to the regulatory body for pharmacies and pharmacists, the General Pharmaceutical Council. A link to their website and an email address for their enquiry team can be found below:”

Source location

Response from MHRA
Page 1 · response
Published 15 October 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

Pharmacy dispensing concerns fall outside the medicines regulator’s remit, which covers medicines placed on the UK market.

Verbatim wording from the response

“We have reviewed the matters of concern and do not believe we are the right organisation to take these matters forward. We are the medicines regulator, and our approvals cover the placing of medicines onto the market, in their original packaging and are designed to ensure the safety, quality and efficacy of medicines on the UK market.”

Source location

Response from MHRA
Page 1 · response
Published 15 October 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

Responsibility for labelling dispensed medicines lies with the regulator, so the service does not provide labelling information.

Verbatim wording from the response

“11. The labelling of dispensed medicines is within the remit of the regulator, the General Pharmaceutical Council, who has also been sent a copy of the Regulation 28 Report. The SPS does not provide information regarding the labelling of dispensed medicines.”

Source location

Response from Specialist Pharmacy Service
Page 3 · response
Published 15 October 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

Dispensing medication is governed by a national pharmacy contract agreed and negotiated nationally, rather than by the local pharmacy committee.

Verbatim wording from the response

“In response to your report, it must be noted that the LPC represents local pharmacy contractors in the delivery of specific pharmacy services to patients living in our community, the dispensing of medication falls within a national pharmacy contract which is agreed, and negotiated at a national level.”

Source location

Response from Community Pharmacy Thames Valley
Page 1 · response
Published 15 October 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

Responsibility for commissioning dispensing medication rests with Frimley ICB, which has raised the matter with NHS England.

Verbatim wording from the response

“With respect to this I have escalated the issues raised with Frimley ICB, who have delegated commissioning for the dispensing of medication, who in turn has raised this matter with NHS England. I have also conversed with our national body – Community Pharmacy England.”

Source location

Response from Community Pharmacy Thames Valley
Page 1 · response
Published 15 October 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

Changes to the Community Pharmacy Contractual Framework fall to NHS England’s pharmacy team to consider.

Verbatim wording from the response

“We recognise that guidance documents alone are often insufficient. Lasting and effective change requires embedding these guidelines within contracts and regulations. We will therefore inform NHS England’s pharmacy team of this case and request that they consider potential changes to the Community Pharmacy Contractual Framework.”

Source location

Response from NHS Frimley ICB
Page 3 · response
Published 15 October 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

There is no single national policy, but existing guidance addresses person-centred medication support for patients with cognitive impairments.

Verbatim wording from the response

“5. Evidence was given at the inquest that there was no guidance or policy in place for pharmacists to follow when issuing medication to patients with cognitive impairments, or if there was, it was not well disseminated among the pharmacist population.”

Source location

Response from NHS Frimley ICB
Page 3 · response
Published 15 October 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

Community pharmacies operate as independent contractors under national contracts, limiting direct influence over their processes.

Verbatim wording from the response

“I am replying as the Chief Pharmacist for NHS Frimley, responsible for medicines optimisation and pharmacy across our system. While we recognise our duty to address the concerns raised, it is important to note that community pharmacies and other healthcare professionals operate as independent contractors under a national framework or contract, limiting our direct influence over their processes.”

Source location

Response from NHS Frimley ICB
Page 1 · response
Published 15 October 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

Different dosette or label colours are not currently available because community-pharmacy dosettes must meet legal labelling requirements.

Verbatim wording from the response

“Dosette boxes are not always or the only solution for supporting a patient in taking their medication. Although various types of dosette boxes are available for purchase by the public, there are only a limited number used within community pharmacy due to the requirement that dosettes used must enable fulfilment of the legal labelling requirements. These are not currently available in different colours or label colours.”

Source location

Response from NHS Frimley ICB
Page 3 · response
Published 15 October 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.20

  1. 1

    Update local resource material to remind healthcare professionals to assess patients’ needs and consider additional needs of others in the home.

    Stated by NHS Frimley Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  2. 2

    Organise a cross-system South-East regional meeting to discuss the issues raised by the report.

    Stated by NHS Frimley Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  3. 3

    Share the response within relevant system and regional quality groups.

    Stated by NHS Frimley Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 15 October 2024.
  4. 4

    Share the Prevention of Future Death Report with pharmacy stakeholders across the South-East region.

    Stated by NHS Frimley Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  5. 5

    Consider ways to continue raising awareness of medication-support issues through future communications and engagement with the pharmacy sector.

    Stated by General Pharmaceutical CouncilStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  6. 6

    Publish equality insight articles supporting inclusive, person-centred pharmacy care for patients with diverse needs.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  7. 7

    Raise the medication-support issue with professional and representative pharmacy bodies.

    Stated by General Pharmaceutical CouncilStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  8. 8

    Publish good-practice examples showing how pharmacies support patients with cognitive impairment and progressive conditions.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  9. 9

    Provide a stability tool and guidance advising original packaging as the preferred option over routine multi-compartment compliance aids.

    Stated by NHS Specialist Pharmacy ServiceStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  10. 10

    Publish a training resource series covering medication-adherence support, including alternatives to multi-compartment compliance aids.

    Stated by NHS Specialist Pharmacy ServiceStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  11. 11

    Raise the matter with the sector-wide Patient Safety Group for consideration by community-pharmacy Medication Safety Officers.

    Stated by National Pharmacy AssociationStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  12. 12

    Discussed the concerns with Community Pharmacy England, the national pharmacy body.

    Stated by Thames Valley LPCStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  13. 13

    Escalated the medication-dispensing concerns to Frimley ICB for commissioning-level consideration.

    Stated by Thames Valley LPCStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  14. 14

    Arrange use of an anonymised case study to share incident learning with local pharmacies.

    Stated by Thames Valley LPCStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  15. 15

    Regularly review dispensing processes to maintain a safe service.

    Stated by Wexham Road pharmacyStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  16. 16

    Organise a cross-system South-East regional meeting to discuss the concerns raised by the case.

    Stated by NHS Frimley Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  17. 17

    Update local resource materials to emphasise assessing patients’ needs, including additional needs of others in the household.

    Stated by NHS Frimley Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  18. 18

    Share the Prevention of Future Death Report with pharmacy stakeholders across the South-East region.

    Stated by NHS Frimley Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
  19. 19

    Inform NHS England’s pharmacy team about the case and request consideration of changes to the Community Pharmacy Contractual Framework.

    Stated by NHS Frimley Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 October 2024.
  20. 20

    Share the response within relevant system and regional quality groups.

    Stated by NHS Frimley Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    The ICB cannot direct pharmacists’ choices about whether particular dosette aids are appropriate.

    Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    The patient’s GP determines clinical need and the resulting medication supply frequency.

    Stated by NHS Frimley Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. 3

    Prescribers, rather than pharmacies, determine the prescribed treatment period for weekly or monthly dispensing.

    Stated by Community Pharmacy England (operating name of the Pharmaceutical Services Negotiating CommitteeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  4. 4

    The pharmacist decides whether a dosette aid is appropriate, and NHS Frimley is unable to direct that choice.

    Stated by NHS Frimley Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Update local resource material to remind healthcare professionals to assess patients’ needs and consider additional needs of others in the home.

Verbatim wording from the response

“As a result of this case, the ICB will be updating local resource material to remind healthcare professionals of the importance of carrying out an assessment and will recommend that in doing so they consider other people in the home that may also have additional needs, as well as the individual patient.”

Source location

Response from Berkshire Integrated Care Board
Page 2 · response
Published 15 October 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

Organise a cross-system South-East regional meeting to discuss the issues raised by the report.

Verbatim wording from the response

“Action: NHS Frimley recognises the seriousness of this tragic case and acknowledges that a similar situation could occur in any system. To address this and increase awareness, we organised a cross-system meeting across the South-East region to discuss the issues raised in this report. This took place on 9 July 2024.”

Source location

Response from Berkshire Integrated Care Board
Page 4 · response
Published 15 October 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

Share the response within relevant system and regional quality groups.

Verbatim wording from the response

“This response is also being shared within the relevant system and regional groups, including our System Quality group and the Regional Quality Group.”

Source location

Response from Berkshire Integrated Care Board
Page 4 · response
Published 15 October 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

Share the Prevention of Future Death Report with pharmacy stakeholders across the South-East region.

Verbatim wording from the response

“Our goal is to learn from this case and take meaningful steps within our remit to prevent similar incidents in the future and share learning nationally. To thoroughly address the concerns raised, we shared the Prevention of Future Death Report [REDACTED] with a diverse group of pharmacy stakeholders across the South-East region to help the ICB respond effectively to the points you raised.”

Source location

Response from Berkshire Integrated Care Board
Page 1 · response
Published 15 October 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 ways to continue raising awareness of medication-support issues through future communications and engagement with the pharmacy sector.

Verbatim wording from the response

“Finally, thank you for raising this matter with us and 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 this issue 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 General Pharmaceutical Council
Page 2 · response
Published 15 October 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

Publish equality insight articles supporting inclusive, person-centred pharmacy care for patients with diverse needs.

Verbatim wording from the response

“Linked to our equality, diversity and inclusion strategy, we have also published a series of equality insight articles. These are designed to support pharmacy teams to deliver person-centred and inclusive”

Source location

Response from General Pharmaceutical Council
Page 1 · response
Published 15 October 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

Raise the medication-support issue with professional and representative pharmacy bodies.

Verbatim wording from the response

“Finally, thank you for raising this matter with us and 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 this issue 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 General Pharmaceutical Council
Page 2 · response
Published 15 October 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

Publish good-practice examples showing how pharmacies support patients with cognitive impairment and progressive conditions.

Verbatim wording from the response

“We have also published good practice examples of what pharmacies are doing to support patients with cognitive impairment and progressive conditions such as developing toolkits for staff, collaborating with other local service providers to support patients showing early signs of progressive conditions, and developing services to meet the needs of patients.”

Source location

Response from General Pharmaceutical Council
Page 2 · response
Published 15 October 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

Provide a stability tool and guidance advising original packaging as the preferred option over routine multi-compartment compliance aids.

Verbatim wording from the response

“7. The content of the series covers all alternatives which may be considered when helping to improve patient adherence. The use of multi-compartment compliance aids (MCAs) is just one of the possible approaches which may be considered, which we cover under Complex medication regimens: supporting adherence as detailed in Annex 1. This resource uses the example of an older person with cognitive impairment as someone who may benefit from a MCA. It also references the MCA pharmacy guide available via the Royal Pharmaceutical Society (professionals are required to become a member of the Royal Pharmaceutical Society to access this guide).”

Source location

Response from Specialist Pharmacy Service
Page 3 · response
Published 15 October 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

Publish a training resource series covering medication-adherence support, including alternatives to multi-compartment compliance aids.

Verbatim wording from the response

“6. We subsequently published in December 2023 a further training resource series on Defining and understanding medication adherence (published on 20 December 2023), which covers the following aspects of adherence:”

Source location

Response from Specialist Pharmacy Service
Page 3 · response
Published 15 October 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

Raise the matter with the sector-wide Patient Safety Group for consideration by community-pharmacy Medication Safety Officers.

Verbatim wording from the response

“We will review our existing guidance and consider how we can refine it. We will consider how we can continue to further raise awareness of this issue with our Member pharmacies. In our role of Medication Safety Officer (MSO) for independent pharmacies, and a member of the sector-wide Patient Safety Group (which also includes representatives of corporate pharmacies), we will also raise this matter with the Group so that it can be considered by all MSOs across community pharmacy.”

Source location

Response from National Pharmacy Association
Page 1 · response
Published 15 October 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

Discussed the concerns with Community Pharmacy England, the national pharmacy body.

Verbatim wording from the response

“With respect to this I have escalated the issues raised with Frimley ICB, who have delegated commissioning for the dispensing of medication, who in turn has raised this matter with NHS England. I have also conversed with our national body – Community Pharmacy England.”

Source location

Response from Community Pharmacy Thames Valley
Page 1 · response
Published 15 October 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

Escalated the medication-dispensing concerns to Frimley ICB for commissioning-level consideration.

Verbatim wording from the response

“With respect to this I have escalated the issues raised with Frimley ICB, who have delegated commissioning for the dispensing of medication, who in turn has raised this matter with NHS England. I have also conversed with our national body – Community Pharmacy England.”

Source location

Response from Community Pharmacy Thames Valley
Page 1 · response
Published 15 October 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

Arrange use of an anonymised case study to share incident learning with local pharmacies.

Verbatim wording from the response

“We do feel it is important however, to ensure that learnings from this incident are shared with local pharmacies, and I have asked that an anonymised case study be used to raise awareness in the local pharmacy community.”

Source location

Response from Community Pharmacy Thames Valley
Page 1 · response
Published 15 October 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

Regularly review dispensing processes to maintain a safe service.

Verbatim wording from the response

“We regularly review our process to ensure we are providing a safe service.”

Source location

Response from Slough Pharmacy
Page 1 · response
Published 15 October 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

Organise a cross-system South-East regional meeting to discuss the concerns raised by the case.

Verbatim wording from the response

“Action: NHS Frimley recognises the seriousness of this tragic case and acknowledges that a similar situation could occur in any system. To address this and increase awareness, we organised a cross-system meeting across the South-East region to discuss the issues raised in this report. This took place on 9 July 2024.”

Source location

Response from NHS Frimley ICB
Page 4 · response
Published 15 October 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

Update local resource materials to emphasise assessing patients’ needs, including additional needs of others in the household.

Verbatim wording from the response

“As a result of this case, the ICB will be updating local resource material to remind healthcare professionals of the importance of carrying out an assessment and will recommend that in doing so they consider other people in the home that may also have additional needs, as well as the individual patient.”

Source location

Response from NHS Frimley ICB
Page 2 · response
Published 15 October 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

Share the Prevention of Future Death Report with pharmacy stakeholders across the South-East region.

Verbatim wording from the response

“Our goal is to learn from this case and take meaningful steps within our remit to prevent similar incidents in the future and share learning nationally. To thoroughly address the concerns raised, we shared the Prevention of Future Death Report [REDACTED] with a diverse group of pharmacy stakeholders across the South-East region to help the ICB respond effectively to the points you raised.”

Source location

Response from NHS Frimley ICB
Page 1 · response
Published 15 October 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

Inform NHS England’s pharmacy team about the case and request consideration of changes to the Community Pharmacy Contractual Framework.

Verbatim wording from the response

“We recognise that guidance documents alone are often insufficient. Lasting and effective change requires embedding these guidelines within contracts and regulations. We will therefore inform NHS England’s pharmacy team of this case and request that they consider potential changes to the Community Pharmacy Contractual Framework.”

Source location

Response from NHS Frimley ICB
Page 3 · response
Published 15 October 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

Share the response within relevant system and regional quality groups.

Verbatim wording from the response

“This response is also being shared within the relevant system and regional groups, including our System Quality group and the Regional Quality Group.”

Source location

Response from NHS Frimley ICB
Page 4 · response
Published 15 October 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 ICB cannot direct pharmacists’ choices about whether particular dosette aids are appropriate.

Verbatim wording from the response

“There are several different brands of dosette boxes available and typically a pharmacy will use one particular brand. The decision about whether such an aid is appropriate is made by the pharmacist, and we are unable to direct this choice.”

Source location

Response from Berkshire Integrated Care Board
Page 3 · response
Published 15 October 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 patient’s GP determines clinical need and the resulting medication supply frequency.

Verbatim wording from the response

“The clinical need of the individual patient is determined by the patients General Practitioner which is used to determine the number of days’ supply of medication. As such this can mean that patients in the same household may be supplied medication at different frequencies.”

Source location

Response from Berkshire Integrated Care Board
Page 2 · response
Published 15 October 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

Prescribers, rather than pharmacies, determine the prescribed treatment period for weekly or monthly dispensing.

Verbatim wording from the response

“Weekly and monthly MCA provision. The medicines prescribed on an (FP10) NHS prescription are dispensed in one go. For various reasons, including reducing medicines waste and additional funding to support the cost of the MCAs, pharmacies generally seek 7-day prescriptions for MDS provision (funding is per prescription so 4 x 7-day prescriptions = 4 x £1.27, receive 4 times more funding than 1 x 28 day prescription = 1 x £1.27). However, the prescriber determines the ‘period of treatment’ (e.g. 7 or 28 days).”

Source location

Response from Community Pharmacy England
Page 2 · response
Published 15 October 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 pharmacist decides whether a dosette aid is appropriate, and NHS Frimley is unable to direct that choice.

Verbatim wording from the response

“There are several different brands of dosette boxes available and typically a pharmacy will use one particular brand. The decision about whether such an aid is appropriate is made by the pharmacist, and we are unable to direct this choice.”

Source location

Response from NHS Frimley ICB
Page 3 · response
Published 15 October 2024

Open published response
Back to top

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