General Pharmaceutical Council
Local Authority
Action Taken
AI-generated response summary
• The General Pharmaceutical Council (GPhC) inspected the pharmacies involved and engaged with their Superintendent Pharmacists, who then implemented measures such as prompt cards and staff reflection on interaction risks. • The GPhC initiated fitness to practise investigations concerning the individuals involved and issued a communication to pharmacy professionals highlighting patient safety concerns, including drug interactions. • The GPhC stated it would write to education bodies, collaborate on a joint communication for Welsh pharmacists, and publish an article on counselling for interactions and higher-risk medicines.
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Dear Rachel Knight In the matter of Lyn Maher
Thank you for sending us the Regulation 28 report following the inquest touching the death of Lyn Maher.
By way of background the GPhC is the independent regulator for pharmacists, pharmacy technicians and pharmacies in Great Britain. Our role is to protect, promote and maintain the health, safety
and wellbeing of members of the public by upholding standards and public trust in pharmacy. This includes maintaining a register of pharmacy professionals and premises, setting regulatory standards and investigating concerns.
Action we have taken
It may be helpful to set out the action we have taken in respect of the pharmacies that supplied clarithromycin to Lyn and the pharmacists involved in making the supplies.
Inspection
Since January 2024 we inspected both pharmacies and found they were meeting our Standards for registered pharmacies which set the minimum requirements to create and maintain the right environment for the safe and effective practice of pharmacy.
We have also spoken with the Superintendent Pharmacists for both pharmacies to establish the actions they have taken to address the risks identified and prevent a recurrence.
One Superintendent Pharmacist told us they had: e Introduced prompt cards in the pharmacy for use when dispensing macrolide antibiotics (which include clarithromycin), so that when patients present with prescriptions for these medicines,
they are asked if they are also taking statins. If the answer is positive, the patient is then counselled and advised to stop taking the statin whilst taking the antibiotics.
pharmacyregulation.org | info@pharmacyregulation.org |020 3713 8000
e Across their chain of pharmacies, they have raised awareness of the interactions between clarithromycin and statins.
Another Superintendent Pharmacist told us they had written to their staff sharing the circumstances and learnings from the inquest and asked staff to reflect upon how they can minimise risk from interactions between the medicines they supply and medicines the patient already takes, especially when they may not have access to the patient’s medical records to establish the patient’s medication regime. In those circumstances the Superintendent Pharmacist advised staff to consider speaking to the patient’s GP to obtain a full medicine history before making a supply, or alternatively suggested staff can access the software platform in England to gain information about the patient’s medication or in Wales, to access data from the Choose Pharmacy platform.
Fitness to practise processes
Our responsibilities include ensuring that pharmacists and pharmacy technicians we register are fit to practise. Being fit to practise involves having the skills, knowledge, health and character to perform their role safely and effectively and behaving in an ethical and trustworthy matter. Pharmacists and pharmacy technicians must also meet our Standards for pharmacy professionals which describe how safe and effective care is delivered.
Where we receive information which may impact upon an individual’s fitness to practise, we can investigate. If our investigation identifies evidence demonstrating a risk of ongoing harm to patients and the public or suggests public confidence in pharmacy will be undermined if action is not taken, a range of measures are available to address the concerns, including (but not limited to) imposing restrictions on an individual’s ability to practise.
In September 2025 we were contacted by the Court and informed of the circumstances in Lyn’s case and asked to produce a witness statement for the inquest. At the conclusion of the inquest, the Court shared the inquest evidence enabling us to investigate whether there are any implications for the fitness to practise of the individuals involved. We started our investigations shortly after the inquest concluded to avoid the risk of potential prejudice to either the inquest or our fitness to practise investigations. As a result, our investigations are at an early stage and we therefore cannot indicate what the outcome will be. We aim to complete fitness to practise investigations as soon as possible and usually within six months of receiving the concern unless the matter is especially complex, in which case investigations may take a little longer to conclude.
It is important to note that fitness to practise is forward looking. The purpose of fitness to practise investigations and proceedings is not to punish individuals for their past actions or omissions, rather it is intended to establish whether an individual can demonstrate the knowledge, skills, health and proper professional conduct and behaviour needed to provide safe and effective care.
Raising awareness
In December 2025 we wrote to all pharmacy owners, pharmacists and pharmacy technicians drawing their attention to emerging patient safety concerns we had identified. We asked them to review the
information provided and to reflect on actions they may need to take to address the issues. We also signposted them to available resources they may find helpful.
Whilst not directly referencing Lyn’s case, one of the areas of concern we highlighted was an incident involving a patient routinely prescribed a long-term medicine who had been provided with an antibiotic where an interaction was present. In this example we explained that these interactions can result in serious patient harm and, although rare, life-threatening outcomes.
We acknowledged that pharmacy teams may not always have access to a patient’s complete medication history, in which case they should take all reasonable steps to ensure supplies of medication made are safe and appropriate. Steps to take include consultations, checking records where possible, providing counselling, and communicating with other healthcare professionals.
Our message emphasised that pharmacists and pharmacy technicians should ensure that interactions are thoroughly checked and patients are counselled on the initiation of medication and made aware if any medication needs temporarily pausing.
Reflections
Interactions and counselling
We recognise that most medicines have the potential to interact with other medicines, as well as with certain foods or medical conditions. Not all interactions are harmful; some can be clinically beneficial and may be used to optimise therapeutic outcomes or reduce adverse effects.
In line with our standards around person-centred care, pharmacists and pharmacy technicians should use their professional judgement to assess the clinical relevance of potential interactions and provide appropriate advice tailored to the individual or their carer. Given the breadth and complexity of potential interactions, within a busy pharmacy setting it is not feasible in routine practice to counsel patients on every possible interaction. Priority should be given to those interactions that are clinically significant and relevant to patient safety, ensuring that information is communicated clearly and supports the safe and effective use of medicines.
Where interactions can be harmful as is the case with clarithromycin and statins, our expectation is that before supplying medicine to the patient or their representative, pharmacy staff will provide appropriate advice and counselling, including advising that if the patient takes statins, they should be stopped until after the patient finishes the short course of antibiotics. This approach ensures the important patient safety message is communicated.
In line with your concerns, we note that there were many missed opportunities whereby neither the
pharmacists, GP or hospital clinicians identified Lyn had been prescribed clarithromycin and statins at the same time. This suggests there is a need to raise further awareness more widely to effect change and improve patient safety. We have highlighted below our proposed next steps in this regard.
Pharmacist education and training
We accredit programmes of initial education and training delivered by the Schools of Pharmacy, including the Master of Pharmacy degree.
Students enrolled on the course are taught learning outcomes which include (but are not limited to) the following:
e consider the quality, safety and risks associated with medicines and products and take appropriate action when producing and supplying them
e appraise the evidence base and apply clinical reasoning and professional judgement to make safe and logical decisions which minimise risk and optimise outcomes for the person
e critically evaluate and use national guidelines and clinical evidence to support safe, rational and cost-effective procurement for the use, and prescribing (by others) of, medicines, devices and services.
During their degree, students learn what is involved in conducting a clinical check.
After successfully completing their degree, trainees then undertake fifty- two weeks of Foundation Training designed to support them to further develop and demonstrate the skills, knowledge and behaviours expected of pharmacists. It also gives them the opportunity to further apply their academic knowledge in practice settings. During this period trainees are supervised in practice and must demonstrate that they meet our learning outcomes.
During their academic studies and in supervised practice prior to registering with us, students and trainees learn about and perform clinical checks, the purpose of which is to ensure the clinical safety and effectiveness of the medicine for the patient. By the time they register with us, we expect they can safely and competently perform all aspects of their role.
Trainees also need to sit and pass the Common Registration Assessment (CRA) before they can apply for registration with us. The CRA is jointly delivered by us and the Pharmaceutical Society of Northern lreland (the regulator of pharmacists and pharmacies in Northern Ireland). The purpose of the CRA is to assure the public that trainees have met a common threshold of applying the knowledge and skills necessary for safe and effective person-centred care and professional practice in the UK at the point of registration.
Once registered, pharmacists and pharmacy technicians must record what they have done each year to keep their knowledge and skills up to date and reflect on how they have put this into practice. This is captured within their revalidation submission to us. Where a pharmacist or pharmacy technician identifies aspects of their knowledge, skills or practice that require further development, our expectation is that they will set out the actions they have taken to address the issue as part of their revalidation.
Clinical checks and the role of the Royal Pharmaceutical Society
Guidance on what is expected when assembling medicines, undertaking a clinical check, and handing out medicines is produced by the Royal Pharmaceutical Society (RPS), the professional leadership body for pharmacists in Great Britain. Currently it is only available to pharmacists who pay to be members of the RPS.
Access to patient records
We agree that if pharmacies in Wales had routine access to appropriate patient medical records the dispensing process should identify and mitigate the risk of harmful interactions between prescribed medications by ensuring pharmacy staff have the information necessary to provide appropriate advice and counselling to patients or their representatives. It is important to note, that even if access were available, it would still be contingent on patient consent.
While community pharmacies in Wales have access to the platform software used to view patient information, they are expected to access GP records only when delivering an NHS-commissioned service and only with the patient’s consent. We understand that access outside of these services should not normally occur unless it is needed in an emergency.
We note that you have shared your concerns with Digital Health and Care Wales who are well placed to explain their requirements for pharmacies in Wales providing NHS services to access patient records and any planned changes to access.
We support and encourage changes to improve access for pharmacy teams to have the information they need to keep patients and the public safe.
Action we will take
We have reflected upon the evidence received during the inquest and the concerns you have expressed within the Regulation 28 report.
In terms of next steps, within the next six weeks we will be writing to the Statutory Education Bodies in Great Britain who are responsible for delivering the Foundation Training year and to the Deans of the Schools of Pharmacy across the UK to share the learnings in Lyn’s case and from other inquests, and to seek their support in raising awareness of the important patient safety issues identified with students and trainees.
We are also in discussions with the Chief Pharmaceutical Officer for Wales and will be collaborating in producing a joint communication to be sent to pharmacists and pharmacy technicians in Wales to further raise awareness of the issues.
We regularly liaise with the RPS and during these meetings, we discuss how we can work together to support patient safety and consider any messaging that needs to be shared with pharmacists and pharmacy technicians. This case has been specifically considered as part of our meetings.
We regularly produce updates for pharmacists and pharmacy technicians on key learnings and insights in Regulate articles which are sent electronically. We will be producing a Regulate article dedicated to appropriate counselling in connection with interactions and higher-risk medicines which will be published in May 2026.
| hope this information is helpful.
Thank you for sending us the Regulation 28 report following the inquest touching the death of Lyn Maher.
By way of background the GPhC is the independent regulator for pharmacists, pharmacy technicians and pharmacies in Great Britain. Our role is to protect, promote and maintain the health, safety
and wellbeing of members of the public by upholding standards and public trust in pharmacy. This includes maintaining a register of pharmacy professionals and premises, setting regulatory standards and investigating concerns.
Action we have taken
It may be helpful to set out the action we have taken in respect of the pharmacies that supplied clarithromycin to Lyn and the pharmacists involved in making the supplies.
Inspection
Since January 2024 we inspected both pharmacies and found they were meeting our Standards for registered pharmacies which set the minimum requirements to create and maintain the right environment for the safe and effective practice of pharmacy.
We have also spoken with the Superintendent Pharmacists for both pharmacies to establish the actions they have taken to address the risks identified and prevent a recurrence.
One Superintendent Pharmacist told us they had: e Introduced prompt cards in the pharmacy for use when dispensing macrolide antibiotics (which include clarithromycin), so that when patients present with prescriptions for these medicines,
they are asked if they are also taking statins. If the answer is positive, the patient is then counselled and advised to stop taking the statin whilst taking the antibiotics.
pharmacyregulation.org | info@pharmacyregulation.org |020 3713 8000
e Across their chain of pharmacies, they have raised awareness of the interactions between clarithromycin and statins.
Another Superintendent Pharmacist told us they had written to their staff sharing the circumstances and learnings from the inquest and asked staff to reflect upon how they can minimise risk from interactions between the medicines they supply and medicines the patient already takes, especially when they may not have access to the patient’s medical records to establish the patient’s medication regime. In those circumstances the Superintendent Pharmacist advised staff to consider speaking to the patient’s GP to obtain a full medicine history before making a supply, or alternatively suggested staff can access the software platform in England to gain information about the patient’s medication or in Wales, to access data from the Choose Pharmacy platform.
Fitness to practise processes
Our responsibilities include ensuring that pharmacists and pharmacy technicians we register are fit to practise. Being fit to practise involves having the skills, knowledge, health and character to perform their role safely and effectively and behaving in an ethical and trustworthy matter. Pharmacists and pharmacy technicians must also meet our Standards for pharmacy professionals which describe how safe and effective care is delivered.
Where we receive information which may impact upon an individual’s fitness to practise, we can investigate. If our investigation identifies evidence demonstrating a risk of ongoing harm to patients and the public or suggests public confidence in pharmacy will be undermined if action is not taken, a range of measures are available to address the concerns, including (but not limited to) imposing restrictions on an individual’s ability to practise.
In September 2025 we were contacted by the Court and informed of the circumstances in Lyn’s case and asked to produce a witness statement for the inquest. At the conclusion of the inquest, the Court shared the inquest evidence enabling us to investigate whether there are any implications for the fitness to practise of the individuals involved. We started our investigations shortly after the inquest concluded to avoid the risk of potential prejudice to either the inquest or our fitness to practise investigations. As a result, our investigations are at an early stage and we therefore cannot indicate what the outcome will be. We aim to complete fitness to practise investigations as soon as possible and usually within six months of receiving the concern unless the matter is especially complex, in which case investigations may take a little longer to conclude.
It is important to note that fitness to practise is forward looking. The purpose of fitness to practise investigations and proceedings is not to punish individuals for their past actions or omissions, rather it is intended to establish whether an individual can demonstrate the knowledge, skills, health and proper professional conduct and behaviour needed to provide safe and effective care.
Raising awareness
In December 2025 we wrote to all pharmacy owners, pharmacists and pharmacy technicians drawing their attention to emerging patient safety concerns we had identified. We asked them to review the
information provided and to reflect on actions they may need to take to address the issues. We also signposted them to available resources they may find helpful.
Whilst not directly referencing Lyn’s case, one of the areas of concern we highlighted was an incident involving a patient routinely prescribed a long-term medicine who had been provided with an antibiotic where an interaction was present. In this example we explained that these interactions can result in serious patient harm and, although rare, life-threatening outcomes.
We acknowledged that pharmacy teams may not always have access to a patient’s complete medication history, in which case they should take all reasonable steps to ensure supplies of medication made are safe and appropriate. Steps to take include consultations, checking records where possible, providing counselling, and communicating with other healthcare professionals.
Our message emphasised that pharmacists and pharmacy technicians should ensure that interactions are thoroughly checked and patients are counselled on the initiation of medication and made aware if any medication needs temporarily pausing.
Reflections
Interactions and counselling
We recognise that most medicines have the potential to interact with other medicines, as well as with certain foods or medical conditions. Not all interactions are harmful; some can be clinically beneficial and may be used to optimise therapeutic outcomes or reduce adverse effects.
In line with our standards around person-centred care, pharmacists and pharmacy technicians should use their professional judgement to assess the clinical relevance of potential interactions and provide appropriate advice tailored to the individual or their carer. Given the breadth and complexity of potential interactions, within a busy pharmacy setting it is not feasible in routine practice to counsel patients on every possible interaction. Priority should be given to those interactions that are clinically significant and relevant to patient safety, ensuring that information is communicated clearly and supports the safe and effective use of medicines.
Where interactions can be harmful as is the case with clarithromycin and statins, our expectation is that before supplying medicine to the patient or their representative, pharmacy staff will provide appropriate advice and counselling, including advising that if the patient takes statins, they should be stopped until after the patient finishes the short course of antibiotics. This approach ensures the important patient safety message is communicated.
In line with your concerns, we note that there were many missed opportunities whereby neither the
pharmacists, GP or hospital clinicians identified Lyn had been prescribed clarithromycin and statins at the same time. This suggests there is a need to raise further awareness more widely to effect change and improve patient safety. We have highlighted below our proposed next steps in this regard.
Pharmacist education and training
We accredit programmes of initial education and training delivered by the Schools of Pharmacy, including the Master of Pharmacy degree.
Students enrolled on the course are taught learning outcomes which include (but are not limited to) the following:
e consider the quality, safety and risks associated with medicines and products and take appropriate action when producing and supplying them
e appraise the evidence base and apply clinical reasoning and professional judgement to make safe and logical decisions which minimise risk and optimise outcomes for the person
e critically evaluate and use national guidelines and clinical evidence to support safe, rational and cost-effective procurement for the use, and prescribing (by others) of, medicines, devices and services.
During their degree, students learn what is involved in conducting a clinical check.
After successfully completing their degree, trainees then undertake fifty- two weeks of Foundation Training designed to support them to further develop and demonstrate the skills, knowledge and behaviours expected of pharmacists. It also gives them the opportunity to further apply their academic knowledge in practice settings. During this period trainees are supervised in practice and must demonstrate that they meet our learning outcomes.
During their academic studies and in supervised practice prior to registering with us, students and trainees learn about and perform clinical checks, the purpose of which is to ensure the clinical safety and effectiveness of the medicine for the patient. By the time they register with us, we expect they can safely and competently perform all aspects of their role.
Trainees also need to sit and pass the Common Registration Assessment (CRA) before they can apply for registration with us. The CRA is jointly delivered by us and the Pharmaceutical Society of Northern lreland (the regulator of pharmacists and pharmacies in Northern Ireland). The purpose of the CRA is to assure the public that trainees have met a common threshold of applying the knowledge and skills necessary for safe and effective person-centred care and professional practice in the UK at the point of registration.
Once registered, pharmacists and pharmacy technicians must record what they have done each year to keep their knowledge and skills up to date and reflect on how they have put this into practice. This is captured within their revalidation submission to us. Where a pharmacist or pharmacy technician identifies aspects of their knowledge, skills or practice that require further development, our expectation is that they will set out the actions they have taken to address the issue as part of their revalidation.
Clinical checks and the role of the Royal Pharmaceutical Society
Guidance on what is expected when assembling medicines, undertaking a clinical check, and handing out medicines is produced by the Royal Pharmaceutical Society (RPS), the professional leadership body for pharmacists in Great Britain. Currently it is only available to pharmacists who pay to be members of the RPS.
Access to patient records
We agree that if pharmacies in Wales had routine access to appropriate patient medical records the dispensing process should identify and mitigate the risk of harmful interactions between prescribed medications by ensuring pharmacy staff have the information necessary to provide appropriate advice and counselling to patients or their representatives. It is important to note, that even if access were available, it would still be contingent on patient consent.
While community pharmacies in Wales have access to the platform software used to view patient information, they are expected to access GP records only when delivering an NHS-commissioned service and only with the patient’s consent. We understand that access outside of these services should not normally occur unless it is needed in an emergency.
We note that you have shared your concerns with Digital Health and Care Wales who are well placed to explain their requirements for pharmacies in Wales providing NHS services to access patient records and any planned changes to access.
We support and encourage changes to improve access for pharmacy teams to have the information they need to keep patients and the public safe.
Action we will take
We have reflected upon the evidence received during the inquest and the concerns you have expressed within the Regulation 28 report.
In terms of next steps, within the next six weeks we will be writing to the Statutory Education Bodies in Great Britain who are responsible for delivering the Foundation Training year and to the Deans of the Schools of Pharmacy across the UK to share the learnings in Lyn’s case and from other inquests, and to seek their support in raising awareness of the important patient safety issues identified with students and trainees.
We are also in discussions with the Chief Pharmaceutical Officer for Wales and will be collaborating in producing a joint communication to be sent to pharmacists and pharmacy technicians in Wales to further raise awareness of the issues.
We regularly liaise with the RPS and during these meetings, we discuss how we can work together to support patient safety and consider any messaging that needs to be shared with pharmacists and pharmacy technicians. This case has been specifically considered as part of our meetings.
We regularly produce updates for pharmacists and pharmacy technicians on key learnings and insights in Regulate articles which are sent electronically. We will be producing a Regulate article dedicated to appropriate counselling in connection with interactions and higher-risk medicines which will be published in May 2026.
| hope this information is helpful.