Christina Fletcher
13 Oct 2017 · Coroner Lisa Hashmi · Manchester (North)
The coroner's concerns
1. risk of medication errors due to similar patient names and addresses
“There is no specific guidance, policy or protocol from the GPhC on the requirement for a 'red flag' system within pharmacies in relation to patients with identical names, similar addresses, living in close proximity etc. as demonstrated by the very tragic circumstances of this case.”
2. inconsistent chain of custody for controlled drugs
“Again, there is no specific guidance, policy or protocol from the Regulator (or indeed legal definition) as to when, where and how the chain of custody (for Controlled Drugs) is completed. It currently appears to be a matter of local practice with some Pharmacies make an entry into the CD Register at the point the CD is handed to the delivery driver, with others making an entry once delivery has been confirmed.”
Responses
Christina-Fletcher_Redacted.pdf ↗· General Pharmaceutical Council
Stated action
“we have written to the SI to provide them with advice to remind him to ensure that all staff, including delivery drivers, are regularly reviewing and refreshing their knowledge of the SOPs, and that locum staff are aware of the pharmacy's SOPs.”