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David Reissner: The risks of ignoring summary care records

"Giving out the wrong medication is currently still an offence"

Lawyer David Reissner points out the pitfalls of not referring to the SCR

The NHS terms of service for community pharmacies in England changed this month. The revised terms of service say that if a pharmacy owner has access to the summary care record (SCR) of a patient, then the record must be accessed if – in the clinical judgement of the pharmacy’s owner – this is in the patient’s best interest.

While it is encouraging to see that the regulations depend on the exercise of clinical judgment, it is odd that the responsibility for exercising this judgment is not placed on the responsible pharmacist, or the pharmacist who makes or supervises the supply, but on the owner – which may be a company.

If we assume that it is a pharmacist who exercises clinical judgement, then when must the SCR be accessed? This may be important in potential situations where a patient is harmed because the prescriber made a mistake that might have been picked up in the pharmacy.

I know of a case in which a patient died because a pharmacist supplied 100mg of morphine sulphate tablets (MST), when the PMR showed that the patient had previously only received 10mg. The pharmacist in that case had to appear before a fitness-to-practise committee.

Royal Pharmaceutical Society guidance on using the SCR says there is no need to refer back to the record every time a repeat prescription is dispensed. Instead, it recommends that the record should be checked:

  • for drug allergies
  • when the patient is new
  • if there are any queries or concerns

Although wrongly failing to consult the SCR could lead to a compensation claim or a fitness-to-practise hearing, it will not be a criminal offence in itself. This highlights how daft it is that giving out the wrong medication is currently still an offence. Even the partial decriminalisation of inadvertent dispensing errors – proposed for later this year – will still leave pharmacists and others at risk of criminal prosecution if the wrong item is given out.


David Reissner is senior healthcare partner at law firm Charles Russell Speechlys LLP ([email protected])

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Harry Tolly, Pharmacist

So why does the DoH and the chubby boys at the GPhC allow a single pharmacist to "clinically check" 500 items a day (around 60 an hour) ??


Totally laughable yet this happens across the England (thousands of pharmacies now dispense at this volume ) and with many pharmacies dispensing even more than this 500 items a day. 


Its the sheer greed and an incompetent contract agreed with a PSNC that is not acting in the professional or public interest.

Pill Counter, Pharmacy

It's never a problem. If [email protected]@t hits the fan it's the Fault of the responsible pharmacist. Send them to GPhC for removal. Get in a new pharmacist. Problem solved. Simple as ABC, 123. But in this instance I think we might see Boots having a word and the regulations being 'tweaked' a little. 

Harry Tolly, Pharmacist


Follow the trail. Its very interesting.

Leon The Apothecary, Student

Without reading it, I suspect we might already know what we'd find. Right?

Leon The Apothecary, Student

Here's a random idea: What would you say to an scehduled time period per patient, say 10 minutes per patient? During this time, clinical checks could be made, SCR accessed, etc. Having a set amount of prescriptions could standarise the workload and with it a reasonable pacing could be set. As a concept, what do you think?

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