Michael Lobban
4 Oct 2019 · Coroner Russell Caller · London Inner (West)
This report repeats 2 earlier warnings. See the linked reports.
The coroner's concerns
1. delayed investigation of missing methadone tablets
“The investigation carried out by The Boots Company PLC into the disparity of Methadone tablets on this occasion was slow and efforts to contact patients who were regular prescription users of methadone was not fully followed through”
2. lack of double check in controlled drug audit
“The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots”
3. absence of physical verification of prescription contents
“There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs”
4. lack of reporting requirements for schedule 2 drug discrepancies
“The General Pharmaceutical Council ("The Council") being the Regulator of Pharmaceutical industry in England and Wales does not have any reporting requirements for pharmacies when discovering a discrepancy in schedule 2 controlled drugs”
5. absence of investigative powers and sanctions for pharmacies
“Moreover there appear to be no investigative powers by The Council where it discovers a disparity of these controlled drugs and as a consequence there are no sanctions in circumstances where pharmacies have mislaid drugs during the course of their handling of controlled drugs”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“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.”
This report
“There appears to be no physical check of the contents of prescription boxes when carrying out the audit of schedule 2 controlled drugs.”
Closely relatedConfidence 0.92 · high
Earlier report
“the system in place for the administration, documentation and audit of processes associated with the use of controlled drugs”
This report
“The audit checking of controlled drugs by The Boots Company PLC is not robust in that there is no double check in place in relation to the audit checking procedure followed by Boots”
Responses
No published response was found on judiciary.uk.