Manipulable medication suitability questionnaire
NHS England received 2 coroners' reports about this hazard between 24 Aug 2018 and 21 Oct 2021.
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 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Permitting the patient to”
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 ... ↗- 3 years 2 months later
Raised again · 1st time
Jamie O'Connor↗
21 Oct 2021 · Dianne Hocking · Leicester City and South Leicestershire
Closely relatedConfidence 0.80 · moderatea different coroner“There was a very limited questionnaire about the history of the person requesting the drugs.”
Original on judiciary.uk ↗ NHS England responded, stating 4 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“we expect pharmacy owners to: - Make sure that their website and the websites of companies they work with are arranged so that a person cannot choose a prescription only medicine and its quantity before there has been an appropriate consultation with a prescriber”
“we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”
Stated timescale: February 2021
2 more stated actions in the Promises tab.
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2018 → 2021Jamie O'Connor3 years 2 months after Karl Willis · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that the questionnaire used to assess suitability for medication can be easily manipulated or lacks sufficient verification, opening the system to abuse.
Karl Willis · 24 Aug 2018
“Permitting the patient to”
Original on judiciary.uk ↗ Jamie O'Connor · 21 Oct 2021
“There was a very limited questionnaire about the history of the person requesting the drugs.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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.”
Stated action
“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.”
What happened next: No evidence found either way
The NHS England statement about enforcing GP contract terms and withholding payments for breaches is not confirmed by any source indicating it was carried out.
“Breach notices and remedial notices are performance related sanctions resulting from breaches of NHS pharmacists' terms of service. The terms of service of NHS pharmacists are set out in Schedule 4 of the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 ("Regulations").”
“Contract breaches, sanctions and termination for primary medical services NHS England Contract breaches, sanctions and termination for primary medical services Document Number: OPS_1013 Issue Date: June 2013 Version Number: 01.01 Status: Approved Next Review Date: June 2014 Page 2 of 55 Contract breaches, sanctions”
No evidence found does not mean the action did not happen.
Stated action
“we expect pharmacy owners to: - Make sure that their website and the websites of companies they work with are arranged so that a person cannot choose a prescription only medicine and its quantity before there has been an appropriate consultation with a prescriber”
Stated action · timescale: February 2021
“we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”
Stated action
“We are also aware that our regulatory partners, including MHRA and the GPhC, share our concerns about the lack of regulatory oversight in this area.”
Stated action
“The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK's legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient's GP before prescribing.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2018 → 2021 | 0.74 | 0.16 | Closely related · 0.80 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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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.