Learning from Gosport: why prescription checks by pharmacists on the ward are essential

The Gosport Independent Panel into patient deaths from opiate overdose concluded that:

  • Opiates were used without appropriate indication;
  • Opiates were started at inappropriately high doses;
  • Opiates were combined with other drugs in high doses[1]

‘Finding Four: Responsibility of the pharmacist’ reported: “There was no evidence available to the Panel to suggest that either the pharmacists or the trust’s Drugs and Therapeutic Committee challenged the practice of prescribing which should have been evident at the time.”

It is of concern to the pharmacy profession that the report identified that clinical checking of prescriptions for opiates and injectable medicines in clinical areas was not performed to the expected pharmacy professional standard[2]

Is there a continued risk to patient safety because clinical checking in some NHS wards is not being performed effectively?

In 2008, the National Patient Safety Agency (NPSA) published a ‘Rapid response report: reducing dosing errors with opioid medicines’[3]
. The NPSA had received reports of five deaths and over 4,200 dose-related patient safety incidents concerning opioid medicines between 2003 and 2008. It can be inferred from this information that opioid prescriptions involved in these incidents had not received an effective clinical check by a pharmacist.

It would be helpful if NHS Improvement would publish more recent data from the National Reporting and Learning System concerning the number of reported incidents of dosing errors involving opioid medicines.

Accountable officers for controlled drugs in NHS hospitals should also be continuously reviewing local incidents involving dosing errors with opioids and taking corrective actions[4]

In conclusion, the importance of clinical checks performed by pharmacists in ward areas has never been more important to ensure patient safety. The General Pharmaceutical Council, Royal Pharmaceutical Society, Care Quality Commission and others should take steps to reassure the public that hospital pharmacists are routinely undertaking effective clinical checks to professional standards.


David Cousins, former head of safe medication practice, National Patient Safety Agency and NHS England


[1] The Gosport Independent Panel. The Gosport Independent Panel Report. 2018. Available at: https://www.gosportpanel.independent.gov.uk/ (accessed July 2018)

[2] Royal Pharmaceutical Society. Medicines Ethics and Practice. Section 2.4 Clinical Checking. 2016. Available at: https://www.rpharms.com/resources/publications/medicines-ethics-and-practice-mep (accessed July 2018)

[3] National Patient Safety Agency. Rapid Response Report. Reducing dosing errors with opioid medicines. NPSA/2008/RRR05. 2008. Available at: https://www.sps.nhs.uk/wp-content/uploads/2018/02/NRLS-1066-Opioid-Medicines-RRR-2008-07-04-v1.pdf (accessed July 2018)

[4] Care Quality Commission. Controlled drugs accountable officers. 2018. Available at: https://www.cqc.org.uk/guidance-providers/controlled-drugs/controlled-drugs-accountable-officers (accessed July 2018)

Last updated
The Pharmaceutical Journal, PJ, August 2018, Vol 301, No 7916;301(7916):DOI:10.1211/PJ.2018.20205162

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