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Death and delays in review of multiples' medicine deliveries

One anonymised incident included 21 failed deliveries to one patient
One anonymised incident included 21 failed deliveries to one patient

A death resulting from medication falling into the wrong hands is one of the case studies featured in a "full review" of delivery processes at the large pharmacy chains.

"A number of serious delivery incidents" at Boots UK prompted the health and beauty giant to call for "policy guidance on delivery issues", according to the Community Pharmacy Patient Safety Group, of which it is a member.

As a result, the group – set up in 2015 by Pharmacy Voice and the medicines safety officers at each of the largest community pharmacy organisations, including Boots UK, Lloydspharmacy, Well and Day Lewis, among others – launched a dedicated website last week (June 21) to share learnings on how to improve patient safety.

The group’s first focus is medicines deliveries, as “most community pharmacies offer a delivery service” and “the number of patients requesting [this service] is increasing”, the group said in a report published to mark the website launch.

The report includes an anonymised case study of the death of an elderly patient's son, after her medication was wrongly delivered to his address (see more details below).

Dogs consuming medicines

Anonymised delivery incidents from the large chains also showed that on one occasion, two dogs consumed a bag of levothyroxine and simvastatin that had been posted through the patient’s letterbox.

In another incident, failure to hand over end-of-life medication diamorphine meant a patient’s daughter wasted “precious time that she could have spent with her father visiting a late night pharmacy to obtain a supply [of the drug], so that he did not die in pain”.

Other examples included 21 failed deliveries to one patient, and an individual with a drug problem stealing several prescription items – including temazepam, diazepam and gabapentin.

See more incidents below.

Reflecting on the challenges

José Moss, Boots UK deputy superintendent and lead author on the Safer delivery of medicines report, told C+D the document is “designed to help people consider and reflect on the challenges that providing such services can pose”.

“The involvement of a responsible pharmacist is crucial in the set-up of this service, so that the patient’s circumstances and needs can be explored, and any necessary permissions sought and documented,” she told C+D on Monday (June 26).

The group identified 10 “insights” into how to improve patient safety during medicines deliveries, and “all member organisations [have] agreed to adopt them in their pharmacy teams’ practice”, the group said.

These include: "hiding medication from the patient is not appropriate"; and "sending medication via the Royal Mail (or other courier service) should only be considered as a last resort".

However, Ms Moss stressed that the paper is not intended to be seen as best practice, but “is expected to assist those community pharmacists who are looking to develop and refine their standard operating procedures (SOPs) in this area”.

Case study 1: "Tragic incident"

A prescription for a monthly blister pack was obtained for an elderly patient, who regularly received home deliveries from her pharmacy. The patient moved from one residence – which she shared with her son – into sheltered housing, and the new address was noted on the prescription. “Regrettably” this was not noticed by the pharmacy team, and the blister pack was sent to the previous address, where the son accepted it. He was later found dead by police, having taken all of his mother’s medicines.

Learning: “This tragic incident demonstrates the importance of obtaining a patient’s permission and only delivering to the patient, or his/her carer or specifically designated person.”

Source: Safer delivery of dispensed medication from community pharmacies


Case study 2: Stolen medicines

After “several problems” with a patient refusing to answer the door and sign for his medicines, the pharmacy delivery driver left four blister packs, insulin from the fridge, and needles, in a shopping trolley outside the patient’s home, on his request. Someone else, known to the patient, took the medication from the trolley, meaning it never reached the intended individual.

Learning: “It is important that the relevant SOPs are followed in full at all times, to make sure that medication is delivered to the individual patient.”

Source: Safer delivery of dispensed medication from community pharmacies


Read the rest of the case studies – and recommendations – in the full report here.

Will you review your medicines delivery processes as a result of this report?

Marc Brooks, Community pharmacist

I still dont know why the GPHC turn a blind eye to widespread delivery by Royal Mail?? Isnt that the Pharmacy2U model?!

When we are inspected, we have to prove we get proof of delivery on our driver tracker forms.... This cannot happen if simply posted through the letter box! Or is it that the powers that be want to encourage online pharmacy???!!







Pharma Tron , Community pharmacist

Indeed, it all seems so rife with inequalities, grubbiness, full of contradictions and inconsistency from top to bottom. I think we should take a leaf out of the GPs book- they would do absolutely nothing for free, and aren't ashamed to do so too, the GMC take a stance and CQC don't even skirt any such contention. We had an inspection recently, and the weighting of the inspection was around 70% on our free stuff, and 30% on our core function as per Human Use of Medicines Regs, Pharmaceutical regs etc. It does my head in that it becomes expected that we do stuff for free and the bar is set so highly... I think what's got me biting in this particular case is that one of the suggestions is that we shouldn't be pulling services because of the adverse effect on social care! If these are leaders of our profession, then we all need to take our heads for a wobble and wake up sharpishly to see that it's on the slide, and no doubts that once the small ones go under, organisations that this very same task group belong to will pick up the detritus, and distance selling pharmacies will Hoover up the majority of the day to day bits repeat items. Apparently the treasury don't wish to invest millions in the distribution of medicines- I just wonder who is paying DSPs' postage costs on that note!! 

Meera Sharma, Community pharmacist

This just highlights even more than ever - pharmacies need to stop offering this free service!! There is austerity all round, community pharmacy is not getting any funding to do this service and the sentence "the number of patients requesting [this service] is increasing”, the group said in a report published " - makes me even more irate - how many of this increased pt numbers need it?? Quite a few of the patients that request the service are doing it for convenience, this was never the target audience, so why are we offering it?! If you keep doing the same thing, you keep getting the same results - less funding! Stop the free deliveries - time to do things differently!

Pharma Tron , Community pharmacist

Biggest source of issues in any pharmacy- MDS and deliveries. On the whole, goodwill services. Yes I know under the equalities act 2010 we make reasonable adjustments to help patients take their medications and have this funded (although is this included in the single activity fee and how much is this actual amount?!), but is this task force set up to scrutinise such services reasonable? Is taking on extra staff to cope with demand for blister packs reasonable? Extending my pharmacy- reasonable? Yet again, we do everything for nothing, then get the rubbish when it hits the fan. Go to a part capitation model of pharmacy then reduce the futile exercise we do, twelve years on from the change of contract, where we chase little slips of green paper (or white ones now!) and that is that. Let us decide who needs what service, let us integrate into the NHS with full record access, and move this profession on. Let's not be scared of the man down the road doing it, and stop being pressured into delivering olive oil ear drops out in the sticks because of fear of numbers dropping! Even dominos pizza wouldn't leave a pizza in a porch or enter someone's house using a key code, and leave a 16inch meat feast in a cupboard! Rant over!

Valentine Trodd, Community pharmacist

Well said.

Kevin Western, Community pharmacist

And there will be no pressure from the DoH  because it wants Mega Hubs which deliver by post into the hands of....who cares....


N O, Pharmaceutical Adviser

Absolutely. That's why Hunt is trying to ex..... the phamcies/ c (y)ists than the CYSTS ON HIS SYSTEM which are more lucerative to HIM AND HIS you know who... why care for patients

Best Farma, Ecommerce

Something tells me GPhC will do nothing.

Valentine Trodd, Community pharmacist

Somebody needs to start holding those clowns to account. They are presiding over the death of a profession with their hands in their pockets.

Best Farma, Ecommerce

The government aren't bothered. just killed hundreds in Grenfell Tower without a care. Now busy checking dodgy cladding after the awful event. These people simply do not care. Patient care is the least of their worries unless there's a major catastrophe one day.........

Bob Dunkley, Locum pharmacist

You are 100% correct.

Uma Patel, Community pharmacist

'sending medication via the Royal Mail (or other courier service) should only be considered as a last resort".

Pharmacy2u is sending by Royal Mail as first option

N O, Pharmaceutical Adviser

I'm Sure there won't be any GPhC investigation on these cases. Sad.

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