“6 7 (1)The Pharmacist in this case gave evidence that he believed that he had a…”

The coroner’s concerns

– 6 7 (1)The Pharmacist in this case gave evidence that he believed that he had a discretion to provide in advance, and not in accordance with the prescription for supervised provision of on specific days, and maintained this was a “standard practice” when the Pharmacy was open for half a day on Saturdays. He interpreted the wording on the prescription namely “please dispense instalments due on a Pharmacy closed days on a prior suitable date” to include Saturdays when the Pharmacy was open for half a day, despite the prescriptions stipulating the specific days that the was to be provided, including specification of the dose each Saturday. (2)This led to a situation where the deceased was in possession of multiple doses of a controlled drug, namely , on a regular basis in the period leading up to his death, which was not in accordance with the prescription, which had been carefully considered to attempt to manage the obvious risks of such. (3)The Pharmacy had been specifically chosen by the deceased’s drug treatment provider because it was able to provide supervised administration of on a 6 day per week basis and because in their assessment this was required to attempt to manage the risks inherent in the deceased having access to multiple doses. (4)The treatment provider were not alerted to the fact that the deceased was regularly receiving additional doses of , not in accordance with the prescription they had issued, and so was unable to risk manage the suitability of the prescribing arrangements. (5)I was not reassured that the Pharmacist fully appreciates the gravity of this situation, and that in evidence he continued to maintain that he could exercise a discretion in relation to the provision of , a controlled drug, and provide this not in accordance with specific prescription instructions on the days specified when the Pharmacy was open, and further that was described as a standard practice. (6)For the avoidance of doubt, the circumstances of this case have been alerted to the General Pharmaceutical Council, as the appropriate regulator, but there has been no update received as to whether an investigation has been undertaken or any action recommended.

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, 2024-0457

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