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recurance

Deborah Headspeath

18 Nov 2019 · Coroner Nigel Parsley · Suffolk

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. lack of centralised prescription database

    “There is no single database that allows a prescribing clinician to identify what prescription only medication has already been prescribed to any particular patient”
  2. 2. unregulated online opiate supply

    “CQC registered pharmacies should now not supply opiate based medications unless the patient provides permission for them to contact their registered GP”
  3. 3. non‑mandatory guidance on online prescriptions

    “New guidance from the General Pharmaceutical Council was issued in April 2019 and this includes specific advice regarding on-line prescriptions”

Linked reports

Raised again laterJamie O'Connor21 Oct 2021 · 1 year 11 months later
Identical hazardConfidence 0.95 · high

This report

“There is no single database that allows a prescribing clinician to identify what prescription only medication has already been prescribed to any particular patient.”

Later report

“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 ↗
Full chain: Lack of centralised prescription database

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error