Uncontrolled prescribing of contraindicated drugs
NHS England received 2 coroners' reports about this hazard between 27 Jan 2014 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 5 specific actions.
The story, report by report
Spacing grows with the time between reports.
“There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”
Original on judiciary.uk ↗ NHS England responded, stating 1 specific action.Response (PDF) ↗
“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).”
- 7 years 9 months later
Raised again · 1st time
Jamie O'Connor↗
21 Oct 2021 · Dianne Hocking · Leicester City and South Leicestershire
Identical hazardConfidence 0.95 · higha different coroner“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom.”
Original on judiciary.uk ↗ Repeated from the earlier report:centraldatabase
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.
- 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.
2014 → 2021Jamie O'Connor7 years 9 months after Judith Marshall · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight the absence of a central database/system to monitor prescription errors and track prescriptions across providers.
Judith Marshall · 27 Jan 2014
“There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”
Original on judiciary.uk ↗ Jamie O'Connor · 21 Oct 2021
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The medicines regulator, the MHRA, has been working with NHS England to develop draft Patient Safety Alerts and guidance to increase adverse incident reporting via the National Reporting and Learning System (NRLS), which is a central database of patient safety incident reports. We continue to work with the MHRA and NHS England to ensuring that pharmacists and pharmacy technicians use the NRLS.”
Stated action
“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).”
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 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 |
|---|---|---|---|---|
| 2014 → 2021 | 0.73 | 0.21 | Identical · 0.95 | 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.