“S are as follows: (brief summary of matters of concern) 1”
Dated 21 Oct 2021, from the coroner for Leicester City and South Leicestershire. Sent to 5 organisations or people.
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 16 Dec 2021. 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 dated21 Oct 2021
- Deadline16 Dec 2021
- Published on judiciary.uk4 Nov 2021
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Department of Health and Social Care | Response publishedPublished on judiciary.uk in November 2021. |
| General Pharmaceutical Council | Response publishedPublished on judiciary.uk in November 2021. |
| NHS England | Deadline passedNo response published on judiciary.uk so far. The 56-day deadline was 16 Dec 2021. A reply may have been sent and not yet published. |
| General Medical Council | Response publishedPublished on judiciary.uk in November 2021. |
| Care Quality Commission | Response publishedPublished on judiciary.uk in November 2021. |
The coroner’s concerns
S are as follows: (brief summary of matters of concern) 1. There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom. This is open to abuse as the person requesting the drugs has potential access to multiple online pharmacies who have no knowledge of what each other have been prescribing thus risking contra-indicated drugs being dispensed or over prescribing of drugs. 2. There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed. If the person requesting the drugs chose not to share with the GP there were no red flags which might indicate further enquiries should be made with that person as to why they did not want to share with the GP. 3. There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed; 4. There was a very limited questionnaire about the history of the person requesting the drugs. If the answer was ‘no’ to one question which meant that the drugs could not be prescribed it was very easy to go back and alter it to ‘yes’ (or vice versa) if that meant that the drugs could be dispensed; 5. Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber; 6. By virtue of where the company prescribing the drugs was registered there was limited regulation. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 16 December 2021. I, the coroner, may extend the period.
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, 2021-0363
- Added to Minute Book
- 8 Oct 2026
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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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