Lack of end-of-day verification of dispensed drugs
NHS England received 2 coroners' reports about this hazard between 27 Jan 2014 and 4 Oct 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 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“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.”
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).”
- 5 years 8 months laterClosely relatedConfidence 0.85 · higha different coroner
“There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs.”
Original on judiciary.uk ↗ Repeated from the earlier report:checkprescription
The most recent report. A response may not be due or published yet.
- 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 → 2019Michael Lobban5 years 8 months after Judith Marshall · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight insufficient verification steps in pharmacy processes leading to potential medication errors.
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.”
Original on judiciary.uk ↗ 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.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We set standards for registered pharmacies which focus on the outcomes we expect to see in registered pharmacies. We inspect registered pharmacies against the standards and produce reports of our findings.”
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).”
No published response from NHS England 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 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 → 2019 | 0.75 | 0.14 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for NHS England
- Delayed referral for neurosurgical care2 reports · 2017–2026
- Inadequate medical documentation oversight2 reports · 2024–2026
- Patients treated in ED corridor due to lack of clinical space3 reports · 2024–2026
- Lack of basic first aid training and CPR training and defibrillator use by Prison Officers and Staff3 reports · 2015–2026
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.