Poor prescription security
Auditing systems lacking the capability to manage the security assurance of prescriptions sent by individual consultants.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
CQC action
78match
Psychiatry-UK LLP
The service must ensure auditing systems have the capability to manage the security assurance of prescriptions sent by individual consultants to patients and pharmacies.
Matched on
terms: prescription, security
PFD report
65match
Douglas Hodges
The coroner noted the absence of a system for NHS Digital to communicate clinical urgency in community pharmacy prescriptions, and Cegedim's software has misleading information about an urgency flagging feature. The report also notes Wells Pharmacy's urgent prescription management trial may not be permanently adopted.
Matched on
terms: prescription
PFD report
65match
Parys Lapper
The coroner noted that individuals can easily manipulate the current prescription system due to a lack of a central record for issued prescriptions. This allows people to obtain excess medication from multiple NHS and private providers acting in isolation.
Matched on
terms: prescription
PFD report
61match
Samuel Duckworth
The coroner identified concerns regarding the ease with which vulnerable individuals can purchase prescription-only drugs online without medical supervision, posing a risk to their health.
Matched on
terms: prescription
PFD report
61match
Steven Fone
The coroner noted a pharmacy allowed customers to interchangeably collect each other's prescriptions without documented consent, raising concerns this practice could facilitate abuse, stock-piling, and increased risk of harm.
Matched on
terms: prescription
PFD report
61match
David Travers
The coroner noted that despite existing measures, individuals can still too easily access multiple prescriptions from different GP surgeries, which creates risks of excessive intake and diversion of prescription drugs to the illegal market.
Matched on
terms: prescription
PFD report
61match
Laura Parsons
The electronic system for repeat prescriptions allowed liquid morphine to be issued without further scrutiny, failing to prompt prescribers to review the patient's medical records where a previous overdose was recorded.
Matched on
terms: prescription
PFD report
61match
Steven Allen
The coroner noted concerns regarding the prescribing of oxycodone and other medications to an individual with a history of addiction, especially when prescriptions were issued via telephone consultations and replacement prescriptions were given with little challenge.
Matched on
terms: prescription
PFD report
61match
Kimberley Liu
Unregulated websites are selling prescription-only medications without requiring prescriptions, enabling repeat orders, and potentially exploiting vulnerable individuals with addictions. There is also concern these sites could provide means for self-harm.
Matched on
terms: prescription
PFD report
61match
Anthony Nixon
The coroner noted that the pharmacist provided controlled drugs in advance, not strictly adhering to supervised prescription terms, which resulted in the deceased possessing multiple doses. The drug treatment provider was not informed of this practice, preventing their risk management of the prescribing arrangements.
Matched on
terms: prescription
PFD report
61match
Christopher Brazil
The coroner raised concerns about unregulated online pharmacies selling prescription-only medicines and controlled drugs, which are easily found and appear legitimate. These sites lack verification of patient medical history, dosage guidance, and safeguards, potentially exposing vulnerable individuals and minors to unsafe medications.
Matched on
terms: prescription
PFD report
57match
Teresa Lonergan
The general practice did not monitor the patient's consumption of controlled drug prescriptions, leading to a significant accumulation of medication. This situation was exacerbated as the care worker administering the drugs did not report medical instructions.
Matched on
terms: prescription
PFD report
57match
Jane Powell
The coroner identified the ease of acquiring large amounts of prescription-only medication online and noted insufficient clarity on actions being taken to address this, posing a significant risk of future deaths.
Matched on
terms: prescription
PFD report
57match
Deborah Headspeath
The coroner identified the absence of a single database for prescription-only medication, which hinders clinicians from identifying previous prescriptions. Concerns also include online prescribers avoiding CQC regulation and new pharmaceutical guidance being advisory rather than mandatory.
Matched on
terms: prescription
PFD report
57match
Sarah Brady
The coroner noted concerns regarding a hospital issuing a 14-day prescription for medication already prescribed by the GP, which contradicted the GP's practice of issuing 7-day prescriptions to a patient with a high overdose risk and erratic compliance. This additional prescription may have contributed to medication stockpiling.
Matched on
terms: prescription
PFD report
57match
Claire Copeland
Concerns were raised regarding arrangements for delivering physical prescription documents, which lack effective mechanisms to confirm delivery, detect failure, or remedy non-delivery, thereby risking discontinuity of medical treatment.
Matched on
terms: prescription
PFD report
57match
Eirwen Hollister
The GP practice lacked a process to ensure a full review by a GP before issuing further prescriptions after a patient had overdosed on prescribed medication.
Matched on
terms: prescription
PFD report
57match
Lilian Board
The coroner noted that the deceased received duplicate prescriptions for the same medication from both a GP and the hospital, which she then used to end her life. Concerns were raised about the absence of checks to prevent such duplicity in prescriptions between primary and secondary care.
Matched on
terms: prescription
PFD report
57match
Tracy McCarthy
The coroner noted Amitriptyline was prescribed above recommended doses and for an unadvised condition, contrary to BNF guidelines. An overdose risk was not flagged, and a change to monthly prescriptions by a less familiar GP provided increased access.
Matched on
terms: prescription
PFD report
57match
Nigel Dixon
The coroner noted concerns regarding the online sale of prescription drugs, specifically Zopiclone, in quantities and doses exceeding medical prescriptions, which increases the risk of overdose and complicates safe prescribing.
Matched on
terms: prescription
PFD report
57match
Margaret Feeney
The coroner noted a lack of measures at Macklin Street Surgery and Daynight pharmacy to prevent excess medication prescriptions for at-risk patients during longer bank holiday periods, increasing overdose risk.
Matched on
terms: prescription
PFD report
57match
Alexandra Roberts
The minimum available insulin prescription quantity was around 10 days of medication, which was large enough to enable an overdose. The coroner noted a smaller amount would have been prescribed if possible to mitigate this risk.
Matched on
terms: prescription
PFD report
57match
Kim Robinson
The coroner identified a need to review the online prescription service, noting its limited access to patient records and lack of features for prescribers to add comments or screen for suicidal ideation. The report also highlights the potential to limit prescription quantities for certain medicines.
Matched on
terms: prescription
Committee recommendation
57match
#168 - Implement new secure systems for distributing and administering prison medication to prevent diversion.
HMPPS should conduct an urgent review of all prescription medication dispensing procedures within prisons to identify and close loopholes exploited for diversion and introduce enhanced supervision of medication queries. New secure systems for distributing and administering medication must be implemented immediately to prevent diversion and protect vulnerable prisoners. (Recommendation, Paragraph 39) Drivers of the demand and impact of...
Matched on
terms: prescription
PFD report
53match
Dorothy Robinson
The coroner noted a continued risk of prescribing errors within the Trust due to the absence of an electronic prescribing system, seeking reassurance and a clear timeline for its introduction.
Matched on
classifier match
CQC action
53match
Victoria Infirmary
The service should make sure that documents such as prescription pads are always maintained securely.
Matched on
terms: prescription
CQC action
53match
Stamford & Rutland Hospital
The trust should ensure that hospital outpatient prescription pads are stored and tracked appropriately to ensure that they are not misused or missing.
Matched on
terms: prescription
PFD report
49match
Christine Stevenson
The coroner raised concerns about the lack of control over the amount of Oramorph medication prescribed. While its morphine content falls below the threshold for controlled drug requirements, large quantities present a serious risk to health and are subject to abuse.
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classifier match
PFD report
49match
Terence Ryan
The GP surgery lacked a formal, documented protocol to ensure consultant-prescribed repeat medications were added to patient records and checked during subsequent visits. Additionally, the NHS Trust had no protocol for vulnerable patients who self-discharge, particularly regarding follow-up to ensure medication and support.
Matched on
classifier match
PFD report
49match
Gemma Macdonald
The coroner raised concerns regarding the online availability of large quantities of medication, noting a lack of systems to verify purchaser suitability or limit transaction amounts and frequency.
Matched on
classifier match
PFD report
49match
Jamie O’Connor
The coroner identified gaps in online prescribing, including no central tracking system for dispensed medications, a lack of mandatory GP notification, and insufficient face-to-face consultations. Concerns also noted easily manipulated patient questionnaires and limited regulation.
Matched on
classifier match
PFD report
49match
Paul Pidgeon
Booker in Wimbledon, and potentially more widely, sold bulk medicinal products to a customer not authorised to supply them to the public, without conducting required status checks. This raises concerns about the risk of future deaths from the sale of large quantities of medicines to unauthorised individuals.
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classifier match
PHSO casework decision
48match
P-003849 - A practice in the Wigan area
A GP practice issued several incorrect prescriptions in October 2022, which could have led to an overdose.
Matched on
terms: prescription
Inquiry recommendation
48match
IHRD-25 - Drug Prescription Documentation
All instances of drug prescription and administration should be entered into the main clinical notes and paediatric pharmacists should monitor, query and, if necessary, correct prescriptions. In the event of correction the pharmacist should inform the prescribing clinician.
Matched on
terms: prescription
IMB recommendation
48match
Drake Hall (2024)
The Board is concerned about the ongoing problems regarding medication management. This has three components: o The process for administration of medications needs a complete and radical overhaul. o A means of controlling prescription medication needs to be found to reduce the risks associated with trading medications. o The design of the dispensary does not facilitate the effective...
Matched on
terms: prescription
PFD report
45match
Andrew Hooper
The coroner raised concerns that medication was not secured and a large, potentially fatal, quantity was prescribed to someone apparently unaware of the dangers to others. The report notes the importance of assessing a person's ability to keep medication safe and documenting this decision.
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classifier match
PFD report
45match
Frances Andrade
The coroner noted insufficient provision of psychiatric counselling advice for vulnerable witnesses and timely explanations to complainants about criminal trial directions. Additionally, measures are needed to secure prescribed medication from family members at overdose risk.
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classifier match
PFD report
45match
Richard Breatnach
The coroner identified gaps in the online prescribing process, including applications allowing false information without prescriber verification with GPs, and the inappropriate prescribing of excessive dihydrocodeine without direct patient assessment.
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classifier match
PFD report
45match
Darren Carrington
The provided text for the Coroner's Concerns section is malformed and does not contain any identifiable specific concerns raised by the coroner.
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classifier match
PFD report
45match
Jennifer Lacey
The coroner noted concerns regarding the free online availability of dangerous and addictive drugs, which can be prescribed without contact with a patient's regular doctor or access to their medical records, and potentially filled in UK pharmacies without further checks.
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classifier match
PFD report
45match
Michael Lobban
Concerns were raised about the slow investigation and incomplete follow-up by Boots regarding methadone tablet disparity, and the lack of robust audit checking for controlled drugs. Additionally, the General Pharmaceutical Council has no reporting requirements, investigative powers, or sanctions for pharmacies discovering Schedule 2 controlled drug discrepancies.
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classifier match
PFD report
45match
Helen Spicer
The coroner noted the absence of restrictions on the import, export, possession, or administration of oral morphine, and that safe custody requirements and signing for collection from pharmacies do not apply.
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classifier match
PFD report
45match
Gavin Pedleham
The coroner notes a lack of regulations governing the storage and handling of Oramorph in community settings, unlike in institutional settings, and no requirement for recipients to keep it safe from others.
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classifier match
PFD report
45match
Rachel Edwards
The report describes Rachel's informal admission to the Woodlands mental health ward in Ipswich on March 6th, 2017, following a significant overdose.
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classifier match
PFD report
45match
Gemma Ralph
The coroner noted insufficient monitoring of sevoflurane bottles at Cannock Chase Hospital, allowing one to be removed undetected. The trust could not confirm the origin of a bottle found at the deceased’s home.
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classifier match
PFD report
45match
John Ellis
The coroner raised concerns about the lack of adequate controls preventing the misuse of potentially lethal drugs by veterinary surgeons. The deceased easily obtained a Schedule 3 Controlled Drug without verification or scrutiny from former employers.
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classifier match
CQC action
45match
Mount Vernon Cancer Centre
The trust must ensure that there are systems and processes operating effectively to safely store, prescribe, administer and record medicines across all core services.
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classifier match
CQC action
45match
Andover War Memorial Hospital
Ensure that there is an accurate process to record medicine related stationary and that this is monitored, including storing, recording and auditing the use of FP10 forms.
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classifier match
CQC action
44match
Worthing Hospital
The trust must ensure the proper and safe management of medicine including prescribing systems.
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classifier match
PHSO casework decision
44match
P-002299 - An practice in the Northumberland area
Mr W complained the Practice mishandled his diazepam prescription and incorrectly prescribed prednisolone, causing him stress, anxiety, and health issues.
Matched on
terms: prescription