Dear Janine Richards Re: In the matter of Anthony Paul Nixon (Ref 1349-2023) Thank you for sending us the Regulation 28 report regarding the death of Anthony Paul Nixon. We are very sorry to hear about this sad death and we would like to pass on our sincere condolences to Mr Nixon’s family. By way of background, the GPhC is the independent regulator for pharmacists, pharmacy technicians and pharmacies in Great Britain. Our main job 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. Following on from your office’s initial email about the case, our requests for further information and the material supplied and the subsequent PFD report, we have considered how the GPhC needs to act to protect the safety of patients, uphold standards and maintain public trust in pharmacy. The GPhC Inspection and Fitness to Practise (FtP) teams have been collaborating closely on this case. As part of this, the pharmacy has recently been inspected by one of our inspectors, who looked for evidence that the pharmacy is meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. The inspection included looking for evidence about the governance arrangements and the way the service for people taking methadone was being delivered. This was to ensure practices in the pharmacy, including supply of daily doses of methadone on days prior to the pharmacy being closed met the requirements of the prescriptions being dispensed. The Inspection report will be published in due course, showing some minor non-compliance and advice being given. Evidence collected during the visit to the pharmacy has been shared with our FtP colleagues. The GPhC FtP team investigates concerns about individual pharmacy professionals where there may be a risk to patient safety and/or where public confidence in pharmacy could be affected. The initial assessment of this case is complete, and an investigation is open. The case has been allocated to a Case

Officer who will consider the findings of the GPhC inspection and whether any further evidence is required. Once the investigation is complete, we will assess the evidence in line with our Threshold Criteria to determine whether further action against the individual pharmacist is required. The details of this case have been discussed with our NHS colleagues in the Accountable Officer team and with the local CD police liaison officer to share any learnings from this case and further actions may be determined by the FtP investigation outcomes. We hope this information is helpful. If you should require any further information, please do not hesitate to contact me.

Dear Janine Richards, Thank you for sending the Regulation 28 report regarding the death of Anthony Paul Nixon. We are very saddened to hear about the death of Mr Nixon and I would like to express our deepest condolences to his family and friends. York Road Pharmacy is a long-established community pharmacy in Peterlee, County Durham. I am the Superintendent Pharmacist and have been here on a full-time basis for the past 5 years. Following on from my attendance at the Inquest and the receipt of the subsequent PFD report, we have considered the matters of concern and the actions to be taken to ensure this does not happen again. We have found the Durham County Council Drug and Alcohol Service Briefing Note: October 2024 helpful in this regard. This briefing describes the flexibility provided by the standard Home Office wording on FP10(MDA) prescriptions, describes changes to the Pharmacy Treatment Agreement and provides an update on how pharmacies can contact the service. We will endeavour at all times to implement and operate within the scope of this guidance going forward. As the guidance indicates, when Agreements are received by the pharmacy we will check that the Service has indicated the correct days of the week on which the supervised consumption service is normally available and inform the Service of any changes. We understand from the guidance on the Home Office approved wording that this is added to prescriptions to enable advance supplies on bank holidays, public holidays, or other irregular or emergency pharmacy closures and does not include advanced supplies for a regular closure of the pharmacy. We have discussed these requirements internally and all staff are aware of the actions required and have considered the guidance fully. I have ensured that staff have fully understood the guidance and the steps we must take. The details of the

case have been discussed with the GPhC Inspector and the Local Pharmaceutical Committee Chief Officer. We are in contact the GPhC as part of their investigation and will implement any actions required as a result.