Inadequate assessment before remote psychotropic prescribing
General Medical Council received 2 coroners' reports about this hazard between 22 Apr 2015 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 6 specific actions.
The story, report by report
Spacing grows with the time between reports.
“He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison”
Original on judiciary.uk ↗ General Medical Council responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“we decided to commence a review of our decision to close the case on the ground that there is new information which may have led to a different decision”
Stated timescale: 8 January 2015
“We will provide you with details of who you can contact in respect of your case.”
- 6 years 6 months later
Raised again · 1st time
Jamie O'Connor↗
21 Oct 2021 · Dianne Hocking · Leicester City and South Leicestershire
Closely relatedConfidence 0.85 · higha different coroner“There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;”
Original on judiciary.uk ↗ General Medical Council 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 General Medical Council
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 → 2021Jamie O'Connor6 years 6 months after Laurence Boyens · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight unsafe prescribing due to lack of direct clinician‑patient interaction when dispensing medication.
Laurence Boyens · 22 Apr 2015
“He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison”
Original on judiciary.uk ↗ Jamie O'Connor · 21 Oct 2021
“There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;”
Original on judiciary.uk ↗
Stated action · timescale: 8 January 2015
“we decided to commence a review of our decision to close the case on the ground that there is new information which may have led to a different decision”
Stated action
“We will provide you with details of who you can contact in respect of your case.”
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 General Medical Council 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 → 2021 | 0.64 | 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.