Skip to content
recurance

Self certification enables unsafe drug access

Identical hazardConfidence 0.96 · high2 reports · 2018–2020 One-page brief (print or PDF)

NHS England received 2 coroners' reports about this hazard between 24 Aug 2018 and 17 Feb 2020.

They came from 2 different coroners in 2 coroner areas. A similar concern was raised again 1 time after the first warning.

A published response was found for 1 of the 1 earlier reports, stating 1 specific action.

2
reports
2
different coroners
2018–2020
years
0.96
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Karl Willis↗

    24 Aug 2018 · Lydia Brown · Exeter and Greater Devon

    “Permitting the patient to "self certify" without any checks he can appropriately access this medication can allow the patient fo give inaccurate answers”
    Original on judiciary.uk ↗

    NHS England responded, stating 1 specific action.Response (PDF) ↗

    “We have responsibility for ensuring that GPs work within the terms of their contract and pharmacies adhere to their Terms of Service which are outlined in the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013). The Board can take action such as issuing breach notices and requiring action or withholding payments in certain circumstances.”

    Web search (Tavily): No evidence found either way

    Breach Notices and Remedial Notices Regulations 70 and ... ↗
  2. 1 year 6 months later

    Raised again · 1st time

    Joseph Gingell↗

    17 Feb 2020 · Caroline Beasley-Murray · Essex

    Identical hazardConfidence 0.96 · higha different coroner
    “Permitting the patient to "self certify" without any checks can allow abuse of the system by those most vulnerable who have addiction problems.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:Permittingpatientselfcertifywithoutchecks

    NHS England responded.Response (PDF) ↗

  3. All reports to NHS England

Next

This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error