Prescription download unavailable leading to medication delay
NHS Digital received 2 coroners' reports about this hazard between 12 Oct 2017 and 6 Nov 2019.
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 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day.”
Original on judiciary.uk ↗ NHS Digital responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The EPS Enhancements survey took place in August 2017 and a”
Stated timescale: up to 24 months
“An improved reporting mechanism has been developed to record actions and results of the audit and support the ongoing maintenance of the changes which have been implemented.”
- 2 years 1 month laterClosely relatedConfidence 0.80 · moderatea different coroner
“The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued.”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to NHS Digital
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.
2017 → 2019Sandra Scott2 years 1 month after Douglas Hodges · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports concern failures that prevent a prescription from being downloaded or accessed by the pharmacy. The earlier issue stems from a time‑limited download policy, while the later issue arises from a GP resetting the system after issuing the prescription.
Douglas Hodges · 12 Oct 2017
“Downloading prescriptions only up to 2.30pm each day, with the aim of labelling all prescriptions downloaded on that day.”
Original on judiciary.uk ↗ Sandra Scott · 6 Nov 2019
“The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“An improved reporting mechanism has been developed to record actions and results of the audit and support the ongoing maintenance of the changes which have been implemented.”
Stated action · timescale: up to 24 months
“The EPS Enhancements survey took place in August 2017 and a”
Stated action
“An improved reporting mechanism has been developed to record actions and results of the audit and support the ongoing maintenance of the changes which have been implemented.”
No published response from NHS Digital was found for this report. It is the most recent report, so a response may not be due or published yet.
- 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 Digital 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 |
|---|---|---|---|---|
| 2017 → 2019 | 0.67 | 0.09 | Closely related · 0.80 | 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.