Lack of GP awareness of prescribed medication
NHS England received 3 coroners' reports about this hazard between 15 Sept 2016 and 4 Nov 2024.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“(3) There was no evidence that the prescriber made any effort to contact Mr [name redacted] GP to find out if the answers that he gave were true.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“NHS England will use this learning to inform its Digital Strategy. We will also include advice to General Practitioners about Special Patient Notes, which are used within the integrated urgent care software so alerts can be set up for NHS 111 call handlers and out of hours general practitioners when they access a particular patient record as part of the Pharmacy Urgent Medicines Supply service being introduced from 1st December 2016.”
Stated timescale: 1st December 2016
- 5 years 1 month later
Raised again · 1st time
Jamie O'Connor↗
21 Oct 2021 · Dianne Hocking · Leicester City and South Leicestershire
Identical hazardConfidence 0.90 · higha different coroner“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed.”
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.
- 3 years laterClosely relatedConfidence 0.90 · higha different coroner
“The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗
- 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.
2016 → 2021Jamie O'Connor5 years 1 month after Richard Breatnach · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the absence of any process to verify prescriptions with the patient's GP. This gap allows patients to obtain medication without GP awareness or confirmation.
Richard Breatnach · 15 Sept 2016
“(3) There was no evidence that the prescriber made any effort to contact Mr [name redacted] GP to find out if the answers that he gave were true.”
Original on judiciary.uk ↗ Jamie O'Connor · 21 Oct 2021
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed.”
Original on judiciary.uk ↗ 2021 → 2024Neil Yates3 years after Jamie O'Connor · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with ensuring that a patient's GP receives timely information about prescribed medicines. The earlier report notes a lack of any requirement to inform the GP, while the later report points to delays in sending that information.
Jamie O'Connor · 21 Oct 2021
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed”
Original on judiciary.uk ↗ Neil Yates · 4 Nov 2024
“The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“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.”
Stated action · timescale: 1st December 2016
“NHS England will use this learning to inform its Digital Strategy. We will also include advice to General Practitioners about Special Patient Notes, which are used within the integrated urgent care software so alerts can be set up for NHS 111 call handlers and out of hours general practitioners when they access a particular patient record as part of the Pharmacy Urgent Medicines Supply service being introduced from 1st December 2016.”
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.”
No specific action could be extracted with a verified quote.
- 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 |
|---|---|---|---|---|
| 2016 → 2021 | 0.74 | 0.17 | Identical · 0.90 | different |
| 2021 → 2024 | 0.77 | 0.14 | Closely related · 0.90 | 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.