“There is no specific guidance, policy or protocol from the GPhC on the requirement for a…”
Dated 13 Oct 2017, from the coroner for Manchester North. Sent to 1 organisation or person.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 8 Dec 2017. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated13 Oct 2017
- Deadline8 Dec 2017
- Published on judiciary.uk27 Nov 2017
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| General Pharmaceutical Council | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 8 Dec 2017. A reply may have been sent and not yet published. |
The coroner’s concerns
1. There is no specific guidance, policy or protocol from the GPhC on the requirement for a ‘red flag’ system within pharmacies in relation to patients with identical names, similar addresses, living in close proximity etc. as demonstrated by the very tragic circumstances of this case. Whilst the Pharmacy in question did have internal processes in place at the time, concern remains that other Pharmacies throughout England and Wales might not, in the absence of specific guidance from their Regulator. 2. Again, there is no specific guidance, policy or protocol from the Regulator (or indeed legal definition) as to when, where and how the chain of custody (for Controlled Drugs) is completed. It currently appears to be a matter of local practice with some Pharmacies make an entry into the CD Register at the point the CD is handed to the delivery driver, with others making an entry once delivery has been confirmed. Both matters potentially give rise to a risk of future deaths in the absence of guidance and/or policy from the Regulator.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2017-0295
- Added to Minute Book
- 8 Oct 2026
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- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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