Look-alike medication packaging leading to dispensing errors
Medicines and Healthcare products Regulatory Agency received 3 coroners' reports about this hazard between 9 Jan 2015 and 20 Jun 2023.
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 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
Original on judiciary.uk ↗ Medicines and Healthcare products Regulatory Agency responded.Response (PDF) ↗
- 4 years 9 months laterClosely relatedConfidence 0.90 · higha different coroner
“The Pharmacy and Nursing Matron [name redacted], concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label.”
Original on judiciary.uk ↗ Medicines and Healthcare products Regulatory Agency responded, stating 5 specific actions.Response (PDF) ↗
“Introducing library conditions within the dispensary. Commencing with immediate effect.”
Stated timescale: immediate effect
“the exit route (after 5pm) from the 31st January department which is currently located next to the 2020 accuracy checking area. Staff will exit the department via the pharmacy reception exit, preventing staff using the dispensary as a thoroughfare”
Stated timescale: 31st January 2020
3 more stated actions in the Promises tab.
- 3 years 8 months laterClosely relatedConfidence 0.85 · higha different coroner
“That the visual similarity of tablets of differing strengths of carbimazole to each other and to aspirin presents a risk of inadvertent overdose;”
Original on judiciary.uk ↗ Medicines and Healthcare products Regulatory Agency responded, stating 1 specific action.Response (PDF) ↗
“The MHRA considers that the only reliable way for unambiguous identification of a particular medicine is via the information printed on the package labelling.”
- All reports to Medicines and Healthcare products Regulatory Agency
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.
2015 → 2019Victor Hall4 years 9 months after Annette Charlton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that look‑alike medication packaging or labeling can lead to dispensing errors because staff rely on superficial cues rather than verifying the product against the prescription.
Annette Charlton · 9 Jan 2015
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
Original on judiciary.uk ↗ Victor Hall · 16 Oct 2019
“The Pharmacy and Nursing Matron [name redacted], concurred that the staff involved in the incident had relied on the word Polyfusor, without actually checking the medication packaging against the prescription chart and label.”
Original on judiciary.uk ↗ 2015 → 2023Anita Graves8 years 5 months after Annette Charlton · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that look‑alike medication appearance can cause dispensing errors. The earlier report focuses on nearly identical outer packaging, while the later report concerns tablet shape and strength similarity to aspirin.
Annette Charlton · 9 Jan 2015
“Manufacturers are able to produce medication in almost identical boxes which is very likely to contribute to dispensing errors and potentially patient deaths.”
Original on judiciary.uk ↗ Anita Graves · 20 Jun 2023
“That the visual similarity of tablets of differing strengths of carbimazole to each other and to aspirin presents a risk of inadvertent overdose;”
Original on judiciary.uk ↗
No specific action could be extracted with a verified quote.
Stated action · timescale: immediate effect
“Introducing library conditions within the dispensary. Commencing with immediate effect.”
Stated action · timescale: 31st January 2020
“the exit route (after 5pm) from the 31st January department which is currently located next to the 2020 accuracy checking area. Staff will exit the department via the pharmacy reception exit, preventing staff using the dispensary as a thoroughfare”
Stated action · timescale: 29th February 2020
“Reviewing the layout of the dispensary with the aim 29th February of separating the areas used for different parts of 2020 the dispensing process and improving the flow of work.”
Stated action · timescale: 30th June 2020
“closed loop dispensing" (linking the 30th June 2020 electronic prescribing system to the pharmacy dispensing system and robot) with the aim of reducing dispensing errors and improving efficiency and therefore reducing the number of staff needed in the dispensary”
Stated action · timescale: 31st December 2019
“Updating the accuracy checking procedure which 31st December will incorporate a second check for all intravenous 2019 fluids.”
Stated action
“The MHRA considers that the only reliable way for unambiguous identification of a particular medicine is via the information printed on the package labelling.”
- 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 Medicines and Healthcare products Regulatory Agency 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 |
|---|---|---|---|---|
| 2015 → 2019 | 0.64 | 0.16 | Closely related · 0.90 | different |
| 2015 → 2023 | 0.63 | 0.09 | Closely related · 0.85 | 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.