Poor prescription security
Auditing systems lacking the capability to manage the security assurance of prescriptions sent by individual consultants.
Source spread
Where this theme appears
This theme appears across 7 independent accountability sources, so the source mix matters as much as the headline total.
1 inquiry rec
39 PFD reports
1 committee rec
1 CQC action
6 IMB recs
12 PHSO decisions
3 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(39)
Teresa Lonergan
Concerns: The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Overdue
Andrew Hooper
Concerns: Unsecured, high-dose medication was prescribed to an individual unaware of its dangers, raising concerns about safe prescribing practices for those unable to manage risks.
Overdue
Frances Andrade
Concerns: Vulnerable witnesses require clear advice on psychiatric counselling and timely explanations of trial proceedings. Additionally, better measures are needed to secure prescription medication from family members with a history of overdoses.
Response (Surrey and Borders Partnership NHS): The Trust has taken steps to ensure staff interactions with family carers recognise the risk of medication misuse and highlight it as an area to be considered. They have also …
Overdue
Dorothy Robinson
Concerns: A persistent risk of prescribing errors due to unaddressed patient intolerances/allergies remains, compounded by the absence of a crucial electronic prescribing system with no clear implementation timeline.
Response (Royal United Hospital Bath): The Trust is investing in a replacement patient administration system and learning from other hospitals implementing e-prescribing. They have strengthened existing processes and are implementing an electronic prescribing module for …
Responded
Samuel Duckworth
Concerns: The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.
Response (Home Office): The Home Office acknowledges concerns about the supply of prescription-only medicines online, noting ongoing work with law enforcement and internet providers to close illegal websites. They highlight international collaboration and …
Responded
Christine Stevenson
Concerns: Large volumes of Oramorph solution, despite containing less than 0.2% morphine, are prescribed without sufficient control. This poses a serious and potentially fatal risk to naive users due to the high total dosage.
Response (Christine Stevenson): Greater Manchester will raise concerns about volumes/strengths of prescribed controlled drugs and provide guidance to prescribers, as well as examine its reporting system to identify high-volume prescribers. They will highlight …
Response (Home Office): The Home Office notes the concerns and states information from the investigation has been added to the Yellow Card Scheme to monitor substances suspected of being misused. The Home Secretary …
Responded
Richard Breatnach
Concerns: Online medication prescribing allowed applicants to provide false information without verification, leading to excessive and inappropriate prescription of an addictive drug without patient contact or correct guidance.
Response (NHS England): NHS England will assimilate current regulatory and professional guidance into one place for online prescribing, and will use this learning to inform its Digital Strategy. They will also include advice …
Overdue
Steven Fone
Concerns: The practice of allowing interchangeable prescription collection by different customers without consent raises concerns about potential abuse, stock-piling, and increased risk of harm or death from medication misuse.
Overdue
Terence Ryan
Concerns: The GP surgery failed to correctly add new anticoagulation medication to repeat prescriptions and lacked a formal protocol for discharge medications. The hospital also lacked a protocol for vulnerable patients who self-discharge, particularly regarding follow-up and essential medication.
Response (Wrightington Wigan and Leigh NHS Trust): Wrightington, Wigan and Leigh NHS Trust has reviewed its self-discharge policy and is communicating its requirements to staff. They are developing auditing of the Hospital Information System to ensure timely …
Response (Grasmere Surgery): The organization provided a blank response.
Responded
Douglas Hodges
Concerns: The absence of a system to communicate clinical urgency for prescriptions between prescribers and community pharmacies on the NHS Spine creates a significant risk for patients.
Response (NHS England): A letter is being drafted to all General Practices in England highlighting high-risk cases when a phone call to the pharmacist should be made. A pilot scheme for Urgent Care …
Response (Well): Well has rolled out Best in Class Prescription Management across its stores, with field operations management team visits to check implementation and provide support. An improved reporting mechanism has been …
Overdue
Jane Powell
Concerns: The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.
Response (Department of Health): The Department of Health provides background on regulations and describes Operation Pangea and the FakeMeds campaign; MHRA will investigate further once it receives information from Greater Manchester Police.
Overdue
Darren Carrington
Concerns: The report is incomplete and does not contain any specific concerns from the coroner.
Response (Commission Alliance): The Commissioning Alliance reports that changes have been made to IT systems to flag up early ordering of scripts, arrangements have been made to ensure staff have time to manage …
Response (North Laine Medical Centre): North Laine Medical Centre has updated its repeat prescribing policy, including tighter controls on controlled drug prescriptions, changes to computer settings to flag early script requests, and new procedures for …
Response (Brighton and Sussex University Hospitals): Brighton and Sussex University Hospitals has fed back concerns about discharge summaries to the Clinical Director for Emergency and Acute Medicine and the Consultant and Governance Lead for Emergency Medicine, …
Responded
David Travers
Concerns: It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit drug market.
Response (Northern Eastern and Western Devon CCG): Devon LMC and NEW Devon CCG will develop a single point of contact for GP practices to raise concerns about patients at risk of drug-related death, provide guidance to GPs …
Responded
Jennifer Lacey
Concerns: Concerns were raised about dangerous, addictive drugs being freely available online and prescribed by foreign doctors without patient contact or GP record access, potentially filled by UK pharmacies without adequate checks.
Response (NHS England): NHS England acknowledges concerns about online availability of potentially dangerous drugs like Tramadol, but states that the death was not a result of NHS services. They are working with other …
Overdue
Michael Lobban
Concerns: Boots' controlled drug audit and investigation processes for methadone disparities were inadequate, and the General Pharmaceutical Council lacks sufficient reporting requirements, investigative powers, and sanctions for such discrepancies.
Overdue
Deborah Headspeath
Concerns: There's no unified database for tracking patient prescriptions, enabling uncoordinated medication supplies, especially from unregulated online prescribers. Advisory guidance for pharmacists on online prescriptions lacks mandatory adherence and clear sanctions.
Response (The Department of Health and Social Care): The Department of Health and Social Care is working with the CQC and regulators to better regulate online prescribers. Measures already taken include co-authoring principles of good practice in remote …
Responded
Gemma Macdonald
Concerns: The unchecked online availability of large quantities of medication, without systems to verify purchaser suitability or limit transaction amounts and frequency, poses a significant risk.
Response (the Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns about online access to medicines and outlines existing regulations and initiatives to improve patient safety, including the Falsified Medicines Directive and …
Overdue
Laura Parsons
Concerns: A patient with a recent morphine overdose history received a repeat prescription for a fatal amount of liquid morphine. Electronic systems failed to flag the overdose history during repeat prescription authorization, lacking critical scrutiny.
Response (Department for Health and Social Care): The Department for Health and Social Care acknowledges the concerns and outlines existing NICE guidance and CQC recommendations regarding the safe use and management of controlled drugs. They highlight the …
Responded
Helen Spicer
Concerns: Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges concerns about opioid overuse and misuse. They outline actions taken, including a PHE evidence review, front-of-pack warnings on opioid medications, and structured …
Response (ACMD): The ACMD acknowledges the concerns and will gather more information on the scale of the issue of morphine sulfate solution misuse, being mindful of its legitimate use. They will request …
Responded
Parys Lapper
Concerns: A fragmented prescription system, lacking central records, allowed a patient to obtain excessive medication from multiple providers, enabling abuse and increasing the risk of fatal overdose.
Response (NHS England): NHS England and NHS Improvement acknowledge concerns about individuals obtaining excess medications and checking prescriptions across providers. They cite GMC guidance on prescribing practices and describe ongoing programs to improve …
Responded
Steven Allen
Concerns: Strong pain medication was prescribed to a patient with a history of drug addiction and self-harm, often through remote consultations, with insufficient challenge or oversight regarding their chaotic lifestyle.
Response (Stockport Clinical Commissioning Group): Stockport CCG's Medicines Management Team is in discussion with Primary Care Network Leads to explore how the Stockport Integrated Pharmacy Service can support practices in medication reviews for vulnerable patients. …
Responded
Sarah Brady
Concerns: A hospital issued an excessive prescription to a high-risk patient with an overdose history, overriding GP-imposed limits and duplicating medication, which potentially enabled stockpiling and increased the risk of overdose.
Response (Sandwell General Hospital): The hospital disputes that Mrs. Brady was oversupplied with medication, stating that medications were generally supplied for short durations and the dispensed Aspirin was within agreed limits.
Responded
Jamie O’Connor
Concerns: Lack of a central medication tracking system, no mandatory GP contact, and insufficient consultation processes in online prescribing platforms risk over-prescription, drug interactions, and patient harm.
Response (GMC): The GMC updated its prescribing guidance in February 2021 to place greater emphasis on good practice principles regardless of consultation method and highlights the need for dialogue with patients and …
Response (GPC): The GPhC outlines its role in setting standards for registered pharmacies and pharmacy professionals and taking enforcement action when standards are not met, including actions against online pharmacies supplying high-risk …
Response (CQC): CQC has been in formal discussion with DHSC and submitted proposals for legislative changes to improve risk management of online primary care providers, and is working with regulatory partners to …
Response (Department of Health and Social Care): DHSC acknowledges the concerns and describes the regulatory framework for medicines, including the roles of MHRA and GPhC, without outlining specific actions beyond existing oversight.
Overdue
Claire Copeland
Concerns: The prescription delivery system is unsafe, relying on physical documents without witnessed delivery or confirmation. It lacks effective mechanisms to detect or remedy failed deliveries, risking discontinuity of vital medical treatment.
Response (HumanKind): Humankind has implemented a standard operating procedure for prescription deliveries, including mandatory witnessed delivery and recording in the service user's notes. They have also established a contact procedure and contingency …
Response (Boots UK): Boots UK acknowledges the concerns raised and states the gravitas is duly noted.
Responded
Eirwen Hollister
Concerns: The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.
Response (NHS England): Heathview Medical Practice has updated its local policy on management of hospital letters, held a teaching event on read coding, produced a new policy/procedure on patient registrations and deductions, and …
Response (Heathview Medical Practice): Heathview Medical Practice reviewed its overdose policy, provided training, and carried out Docman training; it was also reiterated that clinicians should adhere strictly to the practice's overdose policy.
Overdue
Gavin Pedleham
Concerns: There is a lack of regulation governing the safe storage and access of controlled drugs like Oramorph in community settings, unlike highly regulated institutional environments.
Response (Home Office): The Home Office, after consulting with the Department for Health and Social Care, believes that appropriate measures are already in place to reduce the risk of accidents involving liquid morphine …
Response (National Institute for Health and Care Excellence): NICE believes its existing guideline [NG46] on controlled drugs: safe use and management is sufficient, including recommendations for healthcare professionals to advise patients on safe storage and appropriate use.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA will work with marketing authorisation holders to update product information for Oramorph, highlighting the need for secure storage and supervision after dilution.
Responded
Lilian Board
Concerns: A critical lack of checks allowed duplicate prescriptions of the same medication from both a GP and hospital, enabling the deceased to accumulate an excessive amount that she used to end her life.
Response (United Lincolnshire Hospitals NHS Trust): United Lincolnshire Hospitals NHS Trust expresses condolences and clarifies the policy for supplying patients with 14 days of medication upon discharge. They argue that the current policy appropriately balances patient …
Responded
Kimberley Liu
Concerns: Unregulated websites facilitate dangerous, unchecked sales of prescription-only sedative medications, actively instructing customers to evade detection, which exploits vulnerable individuals and poses a suicide risk.
Response (Department of Health and Social Care): The MHRA addresses illegal sale of prescription medications, working with partners across government; the Online Safety Act will give powers to Ofcom to ensure platforms remove illegal content; a national …
Responded
Rachel Edwards
Concerns: The report notes Rachel was informally admitted.
Response (Norfolk and Suffolk NHS Foundation Trust): The Trust will assess medications prescribed upon discharge, which will continue across the Trust. The Trust is planning the technical changes required to build electronic bridges between different elements of …
Responded
Tracy McCarthy
Concerns: Amitriptyline was prescribed above recommended doses for a contraindicated condition in a dependent patient, with overdose risk unflagged after hospitalisation, and risky monthly prescriptions issued due to inadequate record-keeping and over-reliance on individual doctor knowledge.
Response (The GP Partners): The GP Partners plan to implement a Risk Management & Care Planning framework for complex patients, including identifying a lead GP, creating a central register, and conducting regular reviews. An …
Responded
Nigel Dixon
Concerns: Failures in hospital-to-community pharmacy communication allowed a patient access to morphine after cessation. Additionally, the unregulated online sale of Zopiclone in large quantities presented a significant overdose risk.
Response (Department of Health and Social Care): The Department of Health and Social Care outlines enforcement actions against illicit trade of medicines by the MHRA, and strengthening of regulation around online content. NHS England promotes the Discharge …
Overdue
Anthony Nixon
Concerns: A pharmacist unilaterally provided multiple advanced doses of a controlled drug, contrary to supervised prescription instructions and without informing the treatment provider, significantly increasing overdose risk.
Response (General Pharmaceutical Council): The GPhC has inspected the pharmacy, and the inspection report will be published in due course. Evidence collected has been shared with the FtP team who are investigating the case, …
Response (York Road Pharmacy): York Road Pharmacy has reviewed and discussed Durham County Council Drug and Alcohol Service guidance with all staff, and ensured staff understanding of the guidance and the steps required. The …
Responded
Gemma Ralph
Concerns: Inadequate monitoring and auditing of Sevoflurane stock allowed a bottle to be removed from the hospital unflagged. The trust could not confirm if the drug found originated from their facility.
Response (NHS England): NHS England acknowledges concerns about the monitoring of Sevoflurane and refers to professional guidance from the Royal Pharmaceutical Society and CQC regulations. They note the hospital's response and mention internal …
Response (Wolverhampton NHS): The trust has reduced the amount of sevoflurane stored in each theatre and implemented locked drug cupboards. They are also submitting a business case to purchase and install automated medicines …
Responded
John Ellis
Concerns: Inadequate controls and verification processes allowed a veterinary surgeon to easily access a lethal controlled drug, enabling him to misuse it for self-harm without scrutiny.
Response (Veterinary Medicines Directorate): The VMD provides guidance on the use and storage of veterinary controlled drugs and is producing an article reminding vets of their responsibilities. The VMD investigates breaches of the Veterinary …
Response (Royal College of Veterinary Surgeons): The RCVS will consider additional core requirements in the Practice Standards Scheme (PSS) requiring practices to have individualized suicide prevention plans, review the legislative requirements for schedule 2 CDs and …
Responded
Margaret Feeney
Concerns: Inadequate measures exist at the GP surgery and pharmacy to prevent over-prescribing of medication to at-risk patients during extended bank holiday periods, increasing overdose risk.
Response (Macklin Street Surgery): Macklin Street Surgery will create a policy for issuing prescriptions around bank holidays, to be included in induction and locum packs with training offered to relevant staff, and will seek …
Response (Department of Health and Social Care): The DHSC outlines several initiatives already in place, including Summary Medication Reviews, a national programme for non-pharmacological alternatives, publication of a repeat prescribing toolkit, and an oversupply dashboard. They also …
Response (Derby and Derbyshire Integrated Care Board): Derby and Derbyshire Integrated Care Board will ensure system wide engagement and cascade through various channels including: Community Pharmacy Derbyshire Newsletter, GP Key messages delivered to practices by the ICB …
Overdue
Alexandra Roberts
Concerns: The minimum prescribed insulin amount was excessively high (300 units), enabling a large overdose, when a smaller amount would have been preferred to reduce risk.
Response (NHS England): NHS England notes that the MHRA is the more appropriate organisation to respond on insulin doses currently available to patients. The Cheshire and Merseyside ICB will recommend consideration of mental …
Responded
Kim Robinson
Concerns: The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Response (Department of Health and Social Care): DHSC references existing GPhC guidance regarding remote consultations and verifying information to support prescribing decisions, noting that the GPhC is strengthening its guidance and expectations for pharmacy professionals providing remote …
Responded
Christopher Brazil
Concerns: Unregulated online pharmacies easily sell prescription-only and controlled drugs, lacking patient verification, dosage guidance, and safeguards against misuse, exposing vulnerable individuals to unsafe medications.
Response (DSIT): DSIT acknowledges concerns regarding websites offering prescription medicines, noting that the MHRA has taken enforcement action on the websites referenced. They also highlight the Online Safety Act 2023 and its …
Response (Department of Health and Social Care): The Department of Health and Social Care is working with MHRA to identify, disrupt and close down illegal online suppliers of medicines, remove illegal online advertising, implement a web-based reporting …
Responded
Paul Pidgeon
Concerns: A wholesale supplier failed to verify a customer's authorization to distribute medicinal products, leading to bulk sales of paracetamol and ibuprofen to an unauthorized individual, risking future deaths.
Response (Brooker Group Limited): Booker has implemented a tighter customer qualification process requiring refreshment every two years, supported by a system till block preventing sales to unqualified customers, to ensure compliance with Good Distribution …
Responded
CQC inspection actions(1)
IMB individual recommendations(6)
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 administration of …
Governor / Director
Winchester (2021)
Can the installation of a more secure gate to the dispensary on A wing, mentioned last year, be made a priority? (See section 6.3).
Governor / Director
Styal (2023)
The Board continues to have concerns around the safe and timely administration and dispensing of medication. What will be done to address the inadequate accommodation for the pharmacy service including the way in which medicines, including methadone, are transported?
HMPPS
Bedford (2021)
There are issues around the dispensing of medication that need resolving. Some prisoners are not receiving their medication, while others may be selling it on, as there has been inadequate supervision at the pharmacy.
Governor / Director
Cardiff IMB (2025)
Sut bydd y carchar yn sicrhau bod lle storio y gellir ei gloi yn cael ei ddarparu i garcharorion sydd â meddyginiaeth ‘yn eu meddiant’ i helpu i leihau’r risg y bydd carcharorion eraill yn cael gafael ar feddyginiaeth heb ei bresgripsiynu?
Governor / Director
Cardiff (2025)
How will the prison ensure lockable storage is provided for prisoners with ‘in possession’ medication to help reduce the risk of other prisoners accessing unprescribed medication?
Governor / Director
PHSO casework decisions(12)
P-003849 — A practice in the Wigan area
Miss A complains the Practice issued several incorrect prescriptions to her which could have caused her to overdose.
NHS in England
Sep 2023
P-001479 — A medical practice in the London Borough of …
Miss I complains about the care and treatment she has received from her Practice regarding antidepressant and pain relief prescriptions.
NHS in England
Partly Upheld
Jul 2022
P-001747 — A practice in the Essex area
Miss A complains the Practice wrongly prescribed her with an eye ointment when she had an abscess on her left breast.
NHS in England
Partly Upheld
Jan 2023
P-002349 — A practice in the Hertfordshire area
Mrs A complains the Practice did not assess her properly and dismissed symptoms of a stroke. She says it did not check her blood pressure, there was a delay in getting blister packs for her prescription medication and the Practice only agreed to prescribe them temporarily without any charges. She …
NHS in England
Nov 2023
P-002299 — An practice in the Northumberland area
Mr W complains the Practice made mistakes with how it managed his prescriptions.
NHS in England
Partly Upheld
Nov 2023
P-002787 — A practice in the Manchester area
Miss V complains the Practice incorrectly prescribed her antibiotics for a cough without doing a physical examination first.
NHS in England
Jul 2024
P-002812 — A practice in the Oldham area
Mr O complains the Practice did not process his repeat prescription correctly causing a delay and leaving him without vital medication.
NHS in England
Not Upheld
Jul 2024
P-003687 — A practice in the Gedling area
Mrs N complains the Practice consistently failed to properly action paper repeat prescription requests, changed her medication without consent, and refused to prescribe certain dermatology creams.
NHS in England
Jul 2025
P-004566 — A practice in the Reading area
Mrs K complains that her GP surgery made a prescription error and didn't treat this a patient safety matter. She complains it has not completed blood tests it advised it would but has completed tests she did not consent too. Furthermore, she complains it has breached GDPR.
NHS in England
Jan 2026
P-002707 — A practice in the Barking and Dagenham area
Mr A complains the Practice removed warfarin from his repeat prescription and delayed processing a prescription request.
NHS in England
Jun 2024
P-001972 — Royal Devon University Healthcare NHS Foundation Trust
Ms D complains about the Trust's prescription for her acne rosacea.
NHS in England
Apr 2023
P-002998 — A practice in the Sherwood area
Mrs A complains the Practice prescribed her husband antibiotics twice without a physical review or further investigations into the cause of his symptoms.
NHS in England
Sep 2024
LGO / SPSO decisions(3)
PSOW-202407323 — A GP Practice in the area of Cardiff …
We commenced an investigation of Mr B’s complaint against a GP Practice in the area of Cardiff and Vale University Health Board (“the Surgery”) to determine whether the Surgery: • Delayed processing information it received from Mr B’s son (Mr C) about a Shared Care Agreement (“SCA”) which delayed his …
PSOW (Public Services Om…
Health
Aug 2025
PSOW-202303543 — A GP Practice in the area of Cardiff …
Mr X complained that he had been mistreated by his GP Surgery for 14 years. He said that although he had raised his concerns regarding prescription issues, had a meeting with the Practice Manager, and contacted the Ombudsman previously, he was still encountering issues going forward. The Ombudsman found that …
PSOW (Public Services Om…
Health
Aug 2023
PSOW-202404229 — Powys Teaching Health Board
Ms A complained about the provision of hormone medication to her daughter, Ms B, via the GP and the Local Gender Team within the Health Board’s area. The Ombudsman found that the Health Board did not currently have a consistent pathway for gender patients to be prescribed specialist hormone medication …
PSOW (Public Services Om…
Health
Oct 2024