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Comms failure to pharmacy and no records access contributed to suicide

The inquest into Sam Gould's death took place at Huntingdon Town Hall (Credit: Huntingdon Town Hall)

A coroner has called for greater communication between local healthcare providers and for all pharmacies to be involved in medication safety plans for mental health patients.

On September 2, 2018, in the early hours of the morning, Samantha Jane Gould, a teenager living in the Cambridgeshire village of Fulbourn, took a “very large quantity” of prescribed medication she had picked up from her pharmacy the previous afternoon.

The main cause of Ms Gould’s death was her borderline personality disorder, which caused “persistent but unpredictable and fluctuating risk or serious deliberate self-harm and suicide”, coroner Nicholas Moss reported last month (May 28).

However, Mr Moss found in a “wider narrative conclusion” that a “systemic weakness and failing in the lack of a protocol” meant the Child and Adolescent Mental Health Service (CAMHS) and the GP service did not “communicate with local pharmacies concerning 16-18-year-old patients with mental health conditions who were at risk of deliberate overdose”.

CAMHS and Ms Gould’s GP surgery were contacted for comment, but had not responded by the time of going to press.

A spokesperson for Cambridgeshire and Peterborough NHS Foundation Trust said: “We offer our sincere condolences to the family and friends of Samantha Gould, and we will look to continue to work with all partner organisations in light of the findings made by the coroner.”

Pharmacy had no access to patient’s safety plan

An agreed safety plan with Ms Gould’s consultant psychiatrist put the responsibility for her medication with her parents. On August 30, 2018, Ms Gould’s psychiatrist changed her prescription to include topiramate, giving Ms Gould a paper prescription.

According to the coroner’s report, Ms Gould expressed a preference to tell her mother about the change in medication. The psychiatrist had to make a judgement call as to whether or not to breach medical confidence. She chose not to, and Ms Gould did not tell her mother about the new prescription.

The following day, Ms Gould attended her local pharmacy, with a prescription for topiramate and lorazepam. She collected those medications as well as some older prescriptions for other medications she did not know were being held there.

After taking a large amount of the prescription medications, Ms Gould went to bed and died “within at most a couple of hours”, the report said.

“The local pharmacy (who do not have access to patients’ records on SystmOne) had not been told about the safety plan. As Sam was 16-years-old, she was assumed competent to take her own prescriptions and the pharmacists had no immediate reason not to provide them to Sam, being ignorant of the safety plan,” the coroner claimed.

The pharmacy named in the report declined to comment when contacted by C+D.

“No national guidance” on sharing plans with pharmacy

Mr Moss found that there “did not appear to be any national guidance or standards” that encourage “appropriate sharing of risk information and care plans with the local pharmacy”.

“Had the pharmacy been aware of this plan, it is likely that they would either have refused to provide the medication with which Sam overdosed or, at least, contacted Sam’s parents or general practitioner,” he wrote.

While a local protocol has now been introduced to advise pharmacies of relevant care plans for 16-17-year-olds, the coroner expressed the need for “action […] at a national level” to “ensure that pharmacies are appropriately involved in medication safety plans for mental health patients aged 16-17”.

RPS: Pharmacies would welcome greater collaboration

As well as local stakeholders, the coroner’s report was sent to the Royal Pharmaceutical Society (RPS), the General Pharmaceutical Council (GPhC), the Company Chemists’ Association (CCA) and NHS England and NHS Improvement (NHSE&I).

Professor Claire Anderson, chair of RPS in England, described this “tragic case” as “desperately sad for the family and all involved”.

“Pharmacy teams provide vital support every day around mental health and would welcome greater collaboration around medicines safety plans for patients with mental health issues,” Professor Anderson commented.

“Information is central to better patient outcomes, more informed clinical decisions and a greater understanding of the patient’s condition. Pharmacists are the experts in medicines and having access to the patient’s full health record would enable provision of more holistic support, as well as improving high quality, safe and effective patient care,” she added.

A spokesperson for NHSE&I said that it does not comment on individual cases, but the commissioner pointed to its commitment to digitalising clinical processes across healthcare as part of the NHS long-term plan, “reducing time and costs but most importantly enhancing safety”.

The GPhC said it had “noted the coroner’s report” and “will respond in due course”.

Malcolm Harrison, chief executive of the CCA said the organisation “is aware of this extremely sad case and is currently considering the recommendations outlined in the notice. We will respond to the deputy coroner in due course”.

What sort of national protocols for information sharing would you like to see brought forward?

Interleukin -2, Community pharmacist well as some older medications awaiting collection...The amount of times ive seen as a locum the need to boost prescription numbers overide every other common sense clinical considerations in book. Someone should mention to the coroner the financial pressures the sector is facing as a result of government cuts .....

A.S. Singh, Community pharmacist

All this hassle for a £1.24 fee. Pharmacies are increasingly being asked to do things which are either out of scope or not appropriate in a community pharmacy environment (DMS service).


Complete joke anyone thought it was the fault of the pharmacy when all the surgery could have done is asked to remove the old meds from the collection area. Simple

Axed Locum, Locum pharmacist

Irrespective of the remuneration, a "duty of care" is an implied term in contract of services. Therefore when a presciption for new meds is being dispensed, a clinical check should have been carried out, and if there was a need for an intervention, then the pharmacist should have contacted the prescriber or GP for further guidance and appropriateness in the issue of the meds

As for your your comment the surgery could have asked ("the pharmacy to remove the old meds") begs the simple question: How would have the surgery have known that there were meds awaiting collection at the pharmacy?? we need to know which meds were primarily involved in the cause of the death, and then apportion blame accordingly.As a minimum, i believe a call to the GP or the Consultant should have been made before the old meds were issued!!

The GPHC has aways been harking on "pateinet safety as being paramount" should now look into this and implement minimum standards in staffing and skill mix in pharmacies, for the safe and effective delivery of services, and also hold the Suprintendents' jointly or soley liable in any proceedings for negligence determined in a court of law..


TC PA, Community pharmacist

It is a tragic shame that the pharmacy were not told to remove the medication already waiting for collection. Occasionally I have been able to spot the potential for this to happen e.g. when a dose of antiphyschotic has been altered we take off any old scripts for the same medication that haven't been collected. But this is purely done off our own back, no other HCP has ever been proactive and told us.

Hopefully this leads to better communications like the report suggests. Pharmacies cannot be expected to identify these vulnerable patients themselves, especially those where there are different pharmacists and staff working on any given day.

Kevin Western, Community pharmacist

Imagine the furore and teeth gnashing if a pharmacist with knowledge of her condition had pushed the guidelines and this had happened, they would be lining up to hang draw and quarter them, the gphc included... But it was a doctor so that's ok... And why would a doctor talk to a mere pill issuer...

Adam Hall, Community pharmacist

Patients at risk of suicide are usually only prescribed small ammounts (eg weekly prescriptions). If the prescriber was aware of the liklihood of suicide, what half-witted thought compelled them to prescribe a significant quantity? Also, why had they not been in contact directly with the pharmacy to advise of change of meds and to cancel any outstanding prescriptions? The lack of awareness demonstrated by the GP is, frankly, breath-taking

Uma Patel, Community pharmacist

RPS is just a talking shop. GPhC talks only about patient safety

Angela Channing, Community pharmacist

I left the RPS this year, and used the money on subscriptions to Netflix and Amazon prime. Much better use of two hundred quid. Wish I'd done it years ago.

Caroline Jones, Community pharmacist


The prescriber is the one who assessed capacity - and in this case they deemed it safe to issue that quantity of medication.Unfortunately a borderline PD diagnosis will always increase the risk of   suicide.....

Odd that there is no mention of the fact no medication is licensed to treat personality disorder.....a diagnosis of personality disorder should not be made before the age of 18 and there seems to be a lot of medication prescribed in this instance....!

Richard MacLeavy, Dispenser Manager/ Dispensing Assistant

Surely the fault lies within the quantity of medication prescribed and not with the pharmacy! If the pharmacy receives an rx for a not unreasonably large quantity of medication and without any supporting evidence to suggest a suicide risk the pharmacy would have no reason to withhold any part of the medication and in doing so could be accused of failure to supply the medication with reasonable promptness.

V K P, Community pharmacist

this is just mind blowing. Just because there was a supply of medication involved does not mean that the pharmacy should be involved in the checking the safety plan. the consultant did not feel the need to inform the parent so why should the pharmacy breach the confidentiality? And all this grief for a 80p dispensing fee. The coroner should have writtening a damning report against the consultant and the GP. but they would not dare do that or else they would have to face the wrath of the BMA. But RPS and GPhC have not stood up and rebuked the coroner's report. The pharmacy should not be dragged into the flaws elsewhere in the system. The pharmacy should not provide any comment on this farcical report. Furthermore if the pharmacy have been identified and entangled in the matter than they should sue for defamation.

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