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 10 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
39 PFD reports
1 committee rec
3 HSSIB recs
24 CQC actions
6 IMB recs
3 DHR 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.
Inquiry recommendations(2)
2 — Insulin
Recommendation: i. Digital devices should be used to restrict access of insulin to authorised people and record access to insulin storage units. I acknowledge that steps are being taken to achieve this. By 31 March 2027, all neonatal units must meet …
Gov response: It recommends much stronger controls on insulin storage. The NHS has begun that process with new guidance in January of this year, but we agree with the recommendation to go further.
Accepted
IHRD-25 — Drug Prescription Documentation
Recommendation: 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.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
Prevention of Future Deaths reports(39)
Teresa Lonergan
Concerns: 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.
Overdue
Andrew Hooper
Concerns: 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.
Overdue
Frances Andrade
Concerns: 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.
Response (Surrey and Borders Partnership NHS): • Staff interactions with family carers and service users now recognise and highlight the risk of medication access, with comprehensive risk management care plans required for identified risks. • The … (AI summary)
Overdue
Dorothy Robinson
Concerns: 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.
Response (Royal United Hospital Bath): • The hospital uses an electronic prescribing system (ARIA) in specific specialties, which mandates the entry of allergy adverse reactions. • Investment has been made to expand the ARIA system, … (AI summary)
Responded
Samuel Duckworth
Concerns: 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.
Response (Home Office): • The Government and law enforcement agencies work with internet providers to ensure compliance with the law, including the closure of UK-based websites committing offences. • The National Crime Agency, … (AI summary)
Responded
Christine Stevenson
Concerns: 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.
Response (Christine Stevenson): • The coroner's letter has been shared with the Local Intelligence Network (LIN). • The issue of volumes and strengths of controlled drugs prescribed will be raised, and guidance will … (AI summary)
Response (Home Office): • Officials consulted with the Department of Health and the Care Quality Commission regarding the prescribing of opiate medicines. • Information from the investigation was added to the Yellow Card … (AI summary)
Responded
Richard Breatnach
Concerns: 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.
Response (NHS England): • NHS England raised the issues arising from this case at the Care Quality Commission National Controlled Drugs Group. • NHS England hosted a multi-agency meeting to discuss issues related … (AI summary)
Overdue
Steven Fone
Concerns: 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.
Overdue
Terence Ryan
Concerns: 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.
Response (Wrightington Wigan and Leigh NHS Trust): • The Trust acknowledged that its existing 'Self-discharge Against Medical Advice' policy was not consistently applied and that staff awareness was insufficient. • It prepared and disseminated a bulletin on … (AI summary)
Responded
Douglas Hodges
Concerns: 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.
Response (NHS England): • NHS Digital is exploring technical changes to the Electronic Prescription Service (EPS) to allow an urgency flag, which could take up to 24 months to develop and deploy. • … (AI summary)
Response (Well): • Well has rolled out Best in Class Prescription Management across its estate following a pilot. • An improved reporting mechanism has been developed, and SOP14 has been updated and … (AI summary)
Overdue
Jane Powell
Concerns: 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.
Response (Department of Health): • The Department of Health outlined existing legal controls and guidance for online medicine sales, including the General Pharmaceutical Council's (GPhC) Internet Pharmacy Logo and the Medicines and Healthcare products … (AI summary)
Overdue
Darren Carrington
Concerns: The provided text for the Coroner's Concerns section is malformed and does not contain any identifiable specific concerns raised by the coroner.
Response (Commission Alliance): • North Laine Surgery has implemented changes including circulating all reports of patient self-harm to clinical staff. • Records of all patients receiving weekly prescriptions or drugs of potential abuse … (AI summary)
Response (North Laine Medical Centre): • The practice conducted a significant event analysis and developed an action plan. • An audit of Zopiclone prescriptions was completed, and access to online requests for controlled drugs was … (AI summary)
Response (Brighton and Sussex University Hospitals): • The Trust confirmed that feedback regarding inadequate information sharing was provided to relevant clinical leads. • Issues concerning the detail in discharge letters were discussed with medical staff during … (AI summary)
Responded
David Travers
Concerns: 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.
Response (Northern Eastern and Western Devon CCG): • The CCG reviewed the Root Cause Analysis and convened a multi-agency meeting to discuss the coroner's concerns. • The CCG will recommend national changes to NHS Digital regarding immediate … (AI summary)
Responded
Jennifer Lacey
Concerns: 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.
Response (NHS England): • NHS England and the CQC held a workshop in April 2017 to identify challenges in online prescribing and established a UK-wide forum to review the regulatory landscape. • The … (AI summary)
Overdue
Michael Lobban
Concerns: 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.
Overdue
Deborah Headspeath
Concerns: 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.
Response (The Department of Health and Social Care): • A UK-wide regulatory forum was established, leading to the agreement of principles for good practice in remote prescribing and the publication of revised guidance for pharmacist prescribers. • The … (AI summary)
Responded
Gemma Macdonald
Concerns: 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.
Response (the Department of Health and Social Care): • Healthcare regulators co-authored principles for good practice in remote consultations and prescribing, and the General Pharmaceutical Council published revised guidance for pharmacist prescribers. • The Care Quality Commission inspected … (AI summary)
Overdue
Laura Parsons
Concerns: 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.
Response (Department for Health and Social Care): • The GP practice where Ms Parsons was registered reviewed its prescribing processes to ensure compliance with NICE guidance, General Medical Council guidance, and regional protocols. • A report on … (AI summary)
Responded
Helen Spicer
Concerns: 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.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated it works closely with the Home Office and the Advisory Council on the Misuse of Drugs to inform decisions on controlled … (AI summary)
Response (ACMD): • The ACMD's Secretariat developed a standard operating procedure and a watch-list for medicines misuse. • The ACMD agreed to gather further information on the scale of the issue. • … (AI summary)
Responded
Parys Lapper
Concerns: 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.
Response (NHS England): • NHS England is supporting the adoption of electronic prescribing solutions across NHS Trusts, with funding provided for over 80% of Trusts. • Work is underway to define common information … (AI summary)
Responded
Steven Allen
Concerns: 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.
Response (Stockport Clinical Commissioning Group): • The practice undertook a review of the case and its processes for managing prescribing for vulnerable patients. • The Medicines Management Team is discussing with Primary Care Network Leads … (AI summary)
Responded
Sarah Brady
Concerns: 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.
Response (Sandwell General Hospital): • The hospital stated that medications were supplied for limited durations (7 or 5 days) or were not dispensed, with patients receiving their own medications. • The hospital noted that … (AI summary)
Responded
Jamie O’Connor
Concerns: 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.
Response (GMC): • The GMC updated its guidance for doctors on prescribing in February 2021, which places greater emphasis on following good practice principles regardless of the consultation medium. • The updated … (AI summary)
Response (GPC): • The GPC published updated guidance in April 2019 for registered pharmacies providing online services, which includes safeguards for the supply of medicines. • The GPC has taken enforcement action … (AI summary)
Response (CQC): • The CQC routinely checks the management of medicines, prescriptions, consent, and information sharing during inspections of online primary care providers. • The CQC has published guidance for online providers … (AI summary)
Response (Department of Health and Social Care): • The Department undertook a review of the UK's legislative position on digital healthcare provision, identifying gaps related to inappropriate prescribing and a lack of GP checks. • The Department … (AI summary)
Overdue
Claire Copeland
Concerns: 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.
Response (HumanKind): • Humankind implemented a standard operating procedure for prescription delivery, requiring direct handover to pharmacy staff, obtaining a signature, and recording receipt details. • The standard operating procedure includes a … (AI summary)
Responded
Eirwen Hollister
Concerns: 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.
Response (NHS England): • Heathview Medical Practice updated its policy on managing hospital letters and conducted a teaching event for staff on read coding and urgent patient reviews. • Heathview Medical Practice produced … (AI summary)
Response (Heathview Medical Practice): • The practice provided a report following the inquest to prevent future deaths. • The practice provided a Significant Event Analysis. • The practice provided an Overdose Policy. (AI summary)
Overdue
Gavin Pedleham
Concerns: 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.
Response (Home Office): • The Home Office sought views from the Department for Health and Social Care regarding the report. • The Home Office stated it had no plans at present to consider … (AI summary)
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence (NICE) has published guideline NG46 on controlled drugs, which covers safe use and management in all settings, including people's homes. • … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The MHRA stated it would work with Marketing Authorisation holders to update the product information for Oramorph. • The updated product information will highlight the need to keep the … (AI summary)
Responded
Lilian Board
Concerns: 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.
Response (United Lincolnshire Hospitals NHS Trust): • The Trust's policy is to provide patients with a 14-day supply of medication upon discharge to prevent interruption of treatment. • Trust staff have access to the summary care … (AI summary)
Responded
Kimberley Liu
Concerns: 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.
Response (Department of Health and Social Care): • The Medicines and Healthcare products Regulatory Agency (MHRA) operates a Criminal Enforcement Unit to monitor online channels, investigate illegal activity, and remove illegally trading websites. • The Online Safety … (AI summary)
Responded
Rachel Edwards
Concerns: The report describes Rachel's informal admission to the Woodlands mental health ward in Ipswich on March 6th, 2017, following a significant overdose.
Response (Norfolk and Suffolk NHS Foundation Trust): • The Trust stated it would assess medications prescribed upon discharge and is completing a thematic review of deaths where prescribed medication was a cause. • The Trust confirmed it … (AI summary)
Responded
Tracy McCarthy
Concerns: 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.
Response (The GP Partners): • The GP Partners will develop and implement a new framework for managing complex patients, including a Risk Management & Care Planning Register and Care Plan. • The framework will … (AI summary)
Responded
Nigel Dixon
Concerns: 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.
Response (Department of Health and Social Care): • The Medicines and Healthcare products Regulatory Agency (MHRA) has undertaken criminal investigations, made arrests, and implemented measures to delist and block illicit online medicine suppliers. • The Online Safety … (AI summary)
Overdue
Anthony Nixon
Concerns: 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.
Response (General Pharmaceutical Council): • The General Pharmaceutical Council (GPhC) inspected the pharmacy to assess compliance with its Standards for Registered Pharmacies, including governance and methadone service delivery. • Evidence collected during the inspection … (AI summary)
Response (York Road Pharmacy): • The pharmacy stated it would implement and operate within the scope of the Durham County Council Drug and Alcohol Service Briefing Note: October 2024. • The pharmacy confirmed that … (AI summary)
Responded
Gemma Ralph
Concerns: 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.
Response (NHS England): • NHS England stated it would continue to explore and support improvements in the controlled, authorised, and auditable access to medicines. • NHS England indicated it would consider the hospital’s … (AI summary)
Response (Wolverhampton NHS): • The amount of sevoflurane stored in each theatre has been reduced to two bottles, which are kept under direct supervision and locked away at the end of theatre sessions. … (AI summary)
Responded
John Ellis
Concerns: 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.
Response (Veterinary Medicines Directorate): • The VMD provides guidance on the use and storage of veterinary controlled drugs and includes a link to the Vetlife website in inspection reports. • The VMD is producing … (AI summary)
Response (Royal College of Veterinary Surgeons): • RCVS committees will consider additional Practice Standards Scheme requirements for individualised suicide prevention plans. • The RCVS Standards Committee will review legislative requirements for Schedule 2 controlled drugs and … (AI summary)
Responded
Margaret Feeney
Concerns: 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.
Response (Macklin Street Surgery): • The surgery moved the issue day for all short-term prescriptions (14 days or less) to a Tuesday, and advised patients and pharmacies of this change. • It implemented a … (AI summary)
Response (Department of Health and Social Care): • The Department noted that NHS England and partner organisations have been implementing recommendations from the 2021 National overprescribing review. • NHS England is delivering interventions, including supporting Structured Medication … (AI summary)
Response (Derby and Derbyshire Integrated Care Board): • The Integrated Care Board (ICB) committed to sharing process updates with all GP practices, including adjusting prescription collection dates to avoid bank holiday clashes and considering patient-specific needs. • … (AI summary)
Overdue
Alexandra Roberts
Concerns: 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.
Response (NHS England): • A recommendation will be made to ensure that a patient's mental health and wellbeing are considered during annual medication reviews when high-risk medicines are prescribed. • Prescription quantities will … (AI summary)
Responded
Kim Robinson
Concerns: 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.
Response (Department of Health and Social Care): • The General Pharmaceutical Council (GPhC) updated its distance selling guidance in February 2025, introducing strengthened safeguards for online prescribing. • The updated GPhC guidance requires prescribers to independently verify … (AI summary)
Responded
Christopher Brazil
Concerns: 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.
Response (DSIT): • The department noted that the Medicines and Healthcare products Regulatory Agency (MHRA) had taken enforcement action against the websites referenced in the report, resulting in one being offline and … (AI summary)
Response (Department of Health and Social Care): • The General Pharmaceutical Council (GPhC) updated its guidance in February 2025 to strengthen safeguards for online prescribing of medicines requiring additional controls. • The Medicines and Healthcare products Regulatory … (AI summary)
Responded
Paul Pidgeon
Concerns: 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.
Response (Brooker Group Limited): • Booker Group Limited implemented a stringent customer qualification process for medicinal products in April 2025, requiring documented evidence of business type and verification. • A till block was introduced … (AI summary)
Responded
HSSIB safety recommendations(3)
Medication not given: administration of time critical medication in the emergency department
The first eight doses were not prescribed during the patient’s first 24 hours in the ED. The patient self-administered the first four doses.
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
When the medication was prescribed, the morning dose was incorrect.
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation ensure that once a patient’s need for time critical medications is identified, they are prescribed?
Learning Prompt
CQC inspection actions(24)
Rotherham General Hospital
The trust should ensure the process for the safest storage of controlled drugs is fully embedded and actions are taken when issues are identified.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that prescribing charts when not in use are stored securely.
Should Do
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.
Must Do
Hemel Hempstead General Hospital
The trust should ensure that all medicines are stored securely in line with legislation.
Should Do
Cumberland Infirmary
The trust must ensure that controlled drug and other medications should be stored correctly and securely. Regulation 12(1)(2)(g).
Must Do
Cumberland Infirmary
The trust must ensure that controlled drugs and other medications should be stored and recorded correctly and securely. Regulation 12(1)(2)(g).
Must Do
Victoria Infirmary
The service should make sure that documents such as prescription pads are always maintained securely.
Should Do
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.
Should Do
Stamford & Rutland Hospital
The service should ensure that only designated staff have access to medication storage areas within the surgery wards.
Should Do
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.
Should Do
Worthing Hospital
The trust must ensure the proper and safe management of medicine including prescribing systems.
Must Do
The York Hospital
The trust should consider that doors to rooms where medicines are stored are lockable and kept locked when not in use.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatmedicinesarestoredinsecureenvironmentsandthatallentry/exitandcupboarddoorsarelocked.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethattamperproofsealsandmedicineslistsarepresentinalltheseparateboxesusedforspecificconditions.Regulation12(1)(2)(g)
Must Do
Kettering General Hospital
The service should ensure they introduce a system for prescribing medicines that does not have an over reliance on staff for its safety.
Should Do
Kettering General Hospital
The servicemust ensure that there is a clear prescribing audit trail for the supply of over labelled take home medicines.
Must Do
Ellesmere Port Hospital
The trust must be assured that medicines are being stored securely and administered safely as per manufacturing guidance.
Must Do
Birmingham Children's Hospital
The trust must ensure controlled drug records are accurately documented as set out in the Misuse of Drugs regulations 2001 and amendments and there are suitable and safe storage arrangements available for all medicines.
Must Do
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.
Must Do
The Queen Elizabeth Hospital
The service should ensure discarded controlled medicines are recorded in line with trust guidance.
Should Do
Royal Shrewsbury Hospital
The service should ensure the storage of medicines within wards are stored safely and securely.
Should Do
North Devon District Hospital
The service should ensure medicines are stored, managed, prescribed, and administered safely.
Should Do
Doncaster Royal Infirmary
The trust must ensure staff follow the proper and safe management of medicines, and the service uses systems and processes to prescribe and administer medicines safely.
Must Do
Stamford & Rutland Hospital
The trust must ensure that processes related to the safe storage of medicines are maintained and that medicines can only be accessed by persons who are authorised to access them.
Must Do
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
Health investigations(3)
Independent investigation: Asiya Khatun, Newham (2000) — Rec 18
Newham Primary Care Trust should introduce computer systems to monitor repeat prescriptions; these should be sufficiently sensitive to identify irregularities suggestive of poor compliance or of significant under- or over-use of prescribed medication, and should flag to GPs the necessity for consultation with a patient before a further prescription is …
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 16
Newham Primary Care Trust should review its clinical governance protocols regarding repeat prescriptions to ensure that arrangements for issuing repeat prescriptions include suitable provision for monitoring each patient's condition, and for ensuring that patients who need a further examination or assessment do not receive such prescriptions without being seen by …
london
Independent investigation into the care and treatment of Mr J — Rec 3
The Trust and NHS Newham CCG should develop guidelines for the integrated care and treatment of bipolar disorder across primary health and secondary mental health services, which includes guidance for GP’s action with regards to uncollected prescriptions in patients under secondary mental health care.
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
PHSO casework decisions(12)
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.
NHS in England
Sep 2023
P-001479 — A medical practice in the London Borough of …
Miss I complained the Practice abruptly stopped her amitriptyline, inappropriately prescribed pregabalin, provided inadequate pain relief, and delayed responding to her complaint.
NHS in England
Partly Upheld
Jul 2022
P-001747 — A practice in the Essex area
Miss A complained a practice nurse wrongly prescribed an eye ointment for a breast abscess, causing the wound to reopen and worsen, leading to physical and mental distress.
NHS in England
Partly Upheld
Jan 2023
P-002349 — A practice in the Hertfordshire area
Mrs A complained the doctor missed stroke symptoms, failed to check blood pressure, and delayed/incorrectly managed her medication and blister packs.
NHS in England
Nov 2023
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.
NHS in England
Partly Upheld
Nov 2023
P-002787 — A practice in the Manchester area
Miss V complained the Practice incorrectly prescribed antibiotics for a cough without examination, resulting in her developing permanent tinnitus.
NHS in England
Jul 2024
P-002812 — A practice in the Oldham area
Mr O complained the Practice cancelled his monthly prescription, leaving him without medication for five days, which caused severe pain, asthma attacks, and suicidal thoughts.
NHS in England
Not Upheld
Jul 2024
P-003687 — A practice in the Gedling area
Mrs N complained the Practice failed to process multiple repeat prescription requests, inappropriately changed one prescription, and did not act on requests for eczema/psoriasis creams.
NHS in England
Jul 2025
P-004566 — A practice in the Reading area
Mrs K complains about a prescription error, delayed complaint response, an incorrect test being performed, and inappropriate sharing of her healthcare information.
NHS in England
Jan 2026
P-002707 — A practice in the Barking and Dagenham area
Mr A complained his GP Practice unnecessarily removed 5mg warfarin from his repeat prescription and delayed its re-issuance, causing him distress and anxiety.
NHS in England
Jun 2024
P-001972 — Royal Devon University Healthcare NHS Foundation Trust
Ms D complained about the 2014 prescription of Isotretinoin for acne rosacea, alleging it caused severe side effects affecting her arms and legs, preventing her from working.
NHS in England
Apr 2023
P-002998 — A practice in the Sherwood area
Mrs A complained a practice misdiagnosed her father's AML as a chest infection, delaying diagnosis. She also alleged EMAS incorrectly triaged his ambulance call, delaying treatment for an infection.
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
Domestic Homicide Reviews(3)
Southend-on-Sea — recommendation 4
All GP practices across SET, should be moving to electronic prescribing which has functionality for prescriptions to be tracked; this should be embedded as a routine check for all claims of lost prescriptions especially for vulnerable patients and drugs that can cause dependency/abuse. (The CCG medicines management team can support …
NHS Southend ICB
Barnsley — recommendation A3
Send a reminder to all practices to constantly review their repeat prescribing system to avoid duplication of the same class of drug. At the same time make practices aware of the risk of hoarding where there are multiple items on a repeat prescription.
NHS Barnsley ICB
Buckinghamshire — recommendation GP3-2
To review the systems in place that alert the GP Practice to Out of Hours, and vice versa, of each other prescribing and risk monitoring to ensure that there is not over-prescribing, particularly of medication that can lead to addictions.
GP Practice 3