Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of end-of-day verification of dispensed drugs
The earlier warning
Judith Marshall · 27 Jan 2014 · William Coverdale, York
“A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.”
judiciary.uk/prevention-of-future-death-reports/judith-marshall
What was promised
Stated action 1 · response to Judith Marshall (27 Jan 2014) · stated timescale: none stated
“Community pharmacies are required to record patient safety incidents that caused harm or have the potential to cause harm in a pharmacy errors log. They should also report these incidents to the National Reporting and Learning System (NRLS).”
What recurred
- 4 Oct 2019 · Michael Lobban · Russell Caller · Closely related · confidence 0.85 (high)
The clearest link, quoted from both reports:
Earlier · Judith Marshall · 27 Jan 2014
“A mandatory check, by a suitably qualified pharmacist or by a third party, at the end of the day after cashing up on the till, of records of each (prescription only) drug dispensed against the prescription would be a further precaution against a repetition of these circumstances.”
Later · Michael Lobban · 4 Oct 2019
“There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs.”
What happened next
No web check of the stated actions has been published for this chain.