Poor prescription security
Auditing systems lacking the capability to manage the security assurance of prescriptions sent by individual consultants.
63 items
7 sources
1 inquiry
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
Laura Parsons
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.
Matched on
terms: prescription
PFD report
65match
Parys Lapper
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.
Matched on
terms: prescription
PFD report
65match
Kim Robinson
The online prescription system lacks critical safety features, including access to patient records, consent for GP sharing, and suicide screening, enabling unsafe medication access.
Matched on
terms: prescription
PFD report
65match
Christopher Brazil
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.
Matched on
terms: prescription
PFD report
61match
Samuel Duckworth
The ease of purchasing prescription-only drugs like Diazepam via the internet without medical supervision creates an ongoing risk for vulnerable individuals.
Matched on
terms: prescription
PFD report
61match
Steven Fone
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.
Matched on
terms: prescription
PFD report
61match
Terence Ryan
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.
Matched on
terms: prescription
PFD report
61match
Douglas Hodges
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.
Matched on
terms: prescription
PFD report
61match
David Travers
It is too easy for individuals to obtain multiple prescriptions by visiting different GP surgeries, which facilitates drug abuse and the illicit drug market.
Matched on
terms: prescription
PFD report
61match
Jamie O’Connor
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.
Matched on
terms: prescription
PFD report
61match
Claire Copeland
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.
Matched on
terms: prescription
PFD report
61match
Kimberley Liu
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.
Matched on
terms: prescription
PFD report
61match
Tracy McCarthy
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.
Matched on
terms: prescription
PFD report
57match
Frances Andrade
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.
Matched on
terms: prescription
PFD report
57match
Richard Breatnach
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.
Matched on
terms: prescription
PFD report
57match
Jane Powell
The ease with which large quantities of prescription-only medication can be obtained over the internet poses a significant risk of future deaths.
Matched on
terms: prescription
PFD report
57match
Deborah Headspeath
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.
Matched on
terms: prescription
PFD report
57match
Sarah Brady
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.
Matched on
terms: prescription
PFD report
57match
Eirwen Hollister
The GP practice lacked a procedure to prevent further prescriptions after a patient overdose without a mandatory full GP review.
Matched on
terms: prescription
PFD report
57match
Lilian Board
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.
Matched on
terms: prescription
PFD report
57match
Anthony Nixon
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.
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
Andrew Hooper
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.
Matched on
classifier match
PFD report
49match
Dorothy Robinson
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.
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classifier match
PFD report
49match
Gemma Macdonald
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.
Matched on
classifier match
PFD report
49match
Nigel Dixon
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.
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classifier match
PFD report
49match
Gemma Ralph
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.
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classifier match
PFD report
49match
Paul Pidgeon
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.
Matched on
classifier match
PHSO casework decision
48match
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.
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
PHSO casework decision
48match
P-002299 - An practice in the Northumberland area
Mr W complains the Practice made mistakes with how it managed his prescriptions.
Matched on
terms: prescription
PHSO casework decision
48match
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.
Matched on
terms: prescription
PFD report
45match
Teresa Lonergan
The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Matched on
classifier match
PFD report
45match
Christine Stevenson
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.
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classifier match
PFD report
45match
Darren Carrington
The report is incomplete and does not contain any specific concerns from the coroner.
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classifier match
PFD report
45match
Jennifer Lacey
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.
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classifier match
PFD report
45match
Michael Lobban
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.
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PFD report
45match
Helen Spicer
Oral morphine lacks sufficient controls, including import/export restrictions and safe custody requirements, making it easy to obtain without accountability.
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classifier match
PFD report
45match
Steven Allen
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.
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classifier match
PFD report
45match
Gavin Pedleham
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.
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classifier match
PFD report
45match
Rachel Edwards
The report notes Rachel was informally admitted.
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classifier match
PFD report
45match
John Ellis
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.
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PFD report
45match
Margaret Feeney
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.
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classifier match
PFD report
45match
Alexandra Roberts
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.
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classifier match
PHSO casework decision
44match
P-001479 - A medical practice in the London Borough of Lambeth
Miss I complains about the care and treatment she has received from her Practice regarding antidepressant and pain relief prescriptions.
Matched on
terms: prescription
PHSO casework decision
44match
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 complains it got her prescription wrong at first...
Matched on
terms: prescription
PHSO casework decision
44match
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.
Matched on
terms: prescription
PHSO casework decision
43match
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.
Matched on
terms: prescription