Recurance · prevention of future deaths reports
Pre-inquest brief
Self certification enables unsafe drug access
The earlier 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”
What was promised
Stated action 1 · response to Karl Willis (24 Aug 2018) · stated timescale: none stated
“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 recurred
- 17 Feb 2020 · Joseph Gingell · Caroline Beasley-Murray · Identical hazard · confidence 0.96 (high)
The clearest link, quoted from both reports:
Earlier · Karl Willis · 24 Aug 2018
“Permitting the patient to "self certify" without any checks he can appropriately access this medication can allow the patient fo give inaccurate answers”
Later · Joseph Gingell · 17 Feb 2020
“Permitting the patient to "self certify" without any checks can allow abuse of the system by those most vulnerable who have addiction problems.”
What happened next
No evidence found either way · stated action 1
“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").”
Breach Notices and Remedial Notices Regulations 70 and ... · resolution.nhs.uk/…/Primary-Care-Appeals-Breach-and-Remedial-No…
“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”
Contract breaches, sanctions and termination for primary ... · england.nhs.uk/…/con-brea-sanc-term-pms.pdf
No evidence found does not mean the action did not happen.