Samantha Gould

Company Chemists’ Association 
16 Upper Woburn Place 
London 
WC1H 0AF 

www.thecca.org.uk  

15 July 2021 

Mr Nicholas Moss QC 
Assistant coroner  
Cambridgeshire & Peterborough Coroner Service  
Lawrence Court  
Princes St 
Huntingdon  
PE29 3PA 

Dear Mr Moss, 

Inquest into the death of Samantha Gould – regulation 28 notice  

Thank you for providing us with a copy of your report dated 28 May 2021, regarding the tragic death of 
Samantha Gould. First and foremost, I would like to express my sincere condolences to the family of 
Samantha.  

By way of information, the Company Chemists’ Association Limited (CCA) is a trade association 
representing the interests of large multiple community pharmacies. Our members are Asda, Boots, 
LloydsPharmacy, Morrisons, Rowlands, Superdrug, Tesco and Well.  

The CCA represents the interests of its members and provides a forum to bring together their knowledge, 
skills, resources, and experience for the benefit of patients and the NHS. The CCA does not operate any 
community pharmacies, nor do we set standards or provide guidance for our members or other pharmacy 
operators.  As such we are, unfortunately, not in a position to undertake direct action in this regard.  

Having said this, the CCA provides the secretariat for the Community Pharmacy Patient Safety Group 
(CPPSG).  This non-statutory Group brings together representatives from the 19 largest community 
pharmacy organisations to work together to promote patient safety. The CPPSG is driven by the principles 
of sharing and learning. The Group will discuss this tragic incident at its next meeting in July. They will 
consider Samantha’s case to identify learnings and share best practice so that the risk of similar events can 
be prevented. A summary of this discussion will be shared with the community pharmacy network 
nationally via members of the group’s internal communications channels and via the trade press.   

This regulation 28 notice raises an important question about sharing of information and the inclusion of 
community pharmacy in care planning processes. Whilst neither the CCA nor the Patient Safety Group has 
legislative authority to change processes, we do share your concerns.  We will work with the other 
organisations identified in your report (the GPhC, RPS and NHS England) to further consider how practice 
can be improved.   

If there is anything else that you would like us to do in this regard, then please do not hesitate to contact 
me.  

Yours sincerely, 

Chief Executive 

Company Chemists’ Association 16 Upper Woburn Place, London, WC1H 0AF  |  

www.thecca.org.uk

Nicholas Moss QC 
Assistant Coroner, Cambridgeshire and Peterborough 

14 July 2021 

Dear Mr Moss 

Re: REGULATION 28: REPORT TO PREVENT FUTURE DEATHS 

Thank you for sending us your report, raising with us the circumstances surrounding the death of 
Samantha Jane Gould. We are very sorry to hear about this and would like to pass on our sincere 
condolences to Samantha’s family. 

The General Pharmaceutical Council (GPhC) has a statutory purpose to protect patients by setting and 
upholding the standards for registered pharmacies and the standards for pharmacy professionals to 
ensure that registered pharmacies are safe to provide services, and that pharmacy professionals are fit 
to practise. 

We also produce guidance to support pharmacy owners and pharmacy professionals to meet our 
standards. 

The GPhC standards are outcome-focused. This means that we identify the outcomes, rather than the 
specific actions, that pharmacy professionals need to achieve to meet our standards. 

Our standards describe how safe and effective care is delivered through person-centred professionalism 
and require pharmacy professionals to work in partnership with others, where everyone is contributing 
towards providing the person with the care they need. This includes the person and will also include 
other healthcare professionals and teams. For example, carers, relatives and professionals in other 
settings – such as social workers and public health officials. Pharmacy professionals must also take 
action to safeguard people, particularly children and those that are vulnerable. 

All pharmacy professionals are personally accountable for meeting the standards. We expect pharmacy 
professionals to meet our standards, comply with their legal duties, as well as considering any relevant 
guidance when making decisions. 

We have also published guidance for pharmacist prescribers, where we set out the key areas we expect 
pharmacist prescribers to consider when applying the standards to their prescribing practice. The 
guidance states that prescribing information should be shared with the person’s prescriber, or others 

25 Canada Square, London E14 5LQ 

www.pharmacyregulation.org 

 
 involved in their care, so the person receives safe and effective care. All prescribers should use their 
professional judgement when deciding what information to share. 

We will proactively look for opportunities to share the learnings from this extremely sad case with our 
key stakeholders and encourage them to explore how pharmacies can work more effectively with other 
healthcare teams to improve patient outcomes. 

Also, I note that your report has been sent to NHS England. Whilst we produce guidance and advice of 
our standards, NHS England may be better placed to provide you information on medication safety 
plans at a national level. 

We hope this information is helpful. If you should require any further information, please do not 
hesitate to contact me. 

Yours sincerely, 

Chief Executive & Registrar

HM Assistant Coroner 
Mr Nicholas Moss QC 
Cambridgeshire and Peterborough 
Lawrence Court 
Princess Street 
Huntingdon 
PE29 3PA 

National Medical Director 
NHS England & NHS Improvement and 
Interim Chief Executive of NHS 
Improvement 
Skipton House 
80 London Road 
London 
SE1 6LH 

8th September 2021 

Dear Mr Moss, 

Re: Regulation 28 Report to Prevent Future Deaths – Samantha Jane Gould, 
died 2 September 2018  

Thank you for your Regulation 28 Report to Prevent Future Deaths (hereafter 
“report”) dated 28 May 2021 concerning the death of Ms Samantha Gould on 2 
September 2018. Firstly, I would like to express my deep condolences to Ms Gould’s 
family.  I am very sorry it has taken so long to respond and would be grateful if you 
would convey my apologies to Ms Gould’s parents.  

Your report concludes Ms Gould’s death was a result of suicide by an overdose of 
prescribed medication with a wider narrative as follows:  

“There was a systemic weakness and failing in the lack of a protocol for [Child and 
Adolescent Mental Health Service – CAMHS] and the GP service to communicate 
with local pharmacies concerning 16-18 year old patients with mental health 
conditions who were at risk of deliberate overdose. Sam was therefore able to pick 
up older prescriptions on 1 September 2018 without challenge. It was those 
medications … that were fatal in the combined amounts Sam ingested on the night 
of 1-2 September 2018.”  

Following the inquest you raised concerns in your report to NHS England and NHS 
Improvement (NHS E/I) regarding the following points: 

Point 1: There did not appear to be any national guidance or standards that directed 
or encouraged appropriate sharing of risk information and care plans with the local 
pharmacy. As a result, the pharmacy was unsighted on the fact that the treating 
psychiatric team had a safety plan involving Sam’s parents being responsible for 
handling and administering all medication. 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. 

NHS England and NHS Improvement 

 
 Point 2: A local protocol has now been introduced whereby the Cambridgeshire and 
Peterborough Foundation Trust’s Child and Adolescent Mental Health Service 
ensures that any pharmacy used regularly by their patients aged 16-17 are (where 
appropriate) advised of relevant care plans, as well as the responsible GP being so 
informed. This is now to be part of mandatory training for CAMHS prescribing staff 
and is to be discussed in the local Joint Prescribing Group to ensure better 
communication between the local NHS Trusts, G.P.s and local pharmacies. 
Accordingly, action has already been taken in the local area to prevent similar 
fatalities. 

Point 3: I am concerned that there is a risk of future fatalities if action is not taken at 
a national level to ensure that pharmacies are appropriately involved in medication 
safety plans for mental health patients aged 16 – 17, given that such patients may 
otherwise be able to obtain prescribed medication with which to overdose. 

I have set out in the annex some information that is relevant to this tragic incident 
and if used appropriately will help us ensure the risk of this tragic incident happening 
again is minimised. To assist in this I have asked Dr 
Pharmaceutical Officer, to establish a working group to build on the work of the Joint 
Prescribing Group you mention, with the aim of rolling it out, or an improved 
approach, across the country within the next 6 months, and then subsequently to 
ensure that facilities like the Summary Care Record and other digital means are 
used to their full benefit. 

, Deputy Chief 

Thank you for bringing these important patient safety issues to my attention and 
please do not hesitate to contact me should you need any further information. 

Yours sincerely, 

Professor 
National Medical Director   
NHS England and NHS Improvement and 
Interim Chief Executive of NHS Improvement 

 
 
 
 
 
 
 
 
 
 Annex 

The Summary Care Record (SCR) is available to all community pharmacists to view. 
The SCR provides detail about a patient’s current medication and any recent 
changes made by General Practice. The pharmacist must seek consent of the 
patient before they can view it unless they believe there are overriding concerns and 
it is in patient’s best interest that they see the record.  

If the patient’s GP thinks it is helpful that additional information should be available to 
other clinicians who have access to the SCR they can seek agreement with the 
patient that additional information is placed in the SCR for those clinicians to view. 

Not every patient has a SCR and this record does not include any special notes 
made about the patient, but it does provide the opportunity with appropriate consent 
in place to provide additional information:  

“You can also choose to add ‘additional information’ to your Summary Care Record. 
This will include significant medical history and details about immunisations, your 
information and / or communication needs and your personal preferences. This will 
only happen if both you and your GP agree to do this – and you should discuss your 
wishes with your GP practice.” 

NHSE/I has identified that it would be helpful to suggest to GPs that additional 
information could be added to the SCR to flag that a local prescription plan is 
agreed.   HSE/I’s is working with NHS Digital to see how this information can be 
added . 

NHS England » Notes about the Standard and Summary Care Records 

1.  NICE Guideline NG5 (Medicines Optimisation: the safe and effective use of 
medicines to enable to best outcomes) outlines that  “Relevant information 
about medicines should be shared with patients, and their family members or 
carers, where appropriate, and between health and social care practitioners 
when a person moves from one care setting to another, to support 
high-quality care.” GMC Good guidance in prescribing and managing 
medicines and devices outlines that prescribers “must share all relevant 
information with colleagues involved in your patient’s care within and outside 
the team.” 

This includes the sharing of relevant information with the patient’s chosen community 
to ensure safe onward care for the patient and communication of key information in 
relation to prescribed medication. To facilitate secure communication between 
community pharmacies and health professionals, every community pharmacy in 
England is required to have a pharmacy premises specific nhs.net email address. In 
addition, the Electronic Prescription Service system has the facility for prescribers to 
add key messages for the community pharmacy to the electronic prescription. The 
prescriber is also able to annotate any handwritten prescription with key information 
related to the prescribed medication.     

 
 Ref: Nice: 1 Recommendations | Medicines optimisation: the safe and effective use 
of medicines to enable the best possible outcomes | Guidance | NICE 

GMC: Deciding if it is safe to prescribe - GMC (gmc-uk.org)

Nicholas Moss 
Cambridgeshire & Peterborough Coroner Service   
Lawrence Court  
Princes Street  
Huntingdon  
PE29 3PA 

1 July 2021 

Dear Nicholas Moss, 

RE: Samantha Jane Gould Deceased 

Thank you for your letter dated 28th May 2021 following the recent inquest into the death 
of Samantha Jane Gould. We would like to express our sincere condolences to 
Samantha’s family.  

As you may know the Royal Pharmaceutical Society (‘RPS’) is the professional body for 
pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. Our 
role is to lead and support the development of the pharmacy profession.  

We understand the matters of concern which you have raised and are keen to assist 
where we can. Our considerations on the concerns you have raised are as follows:  

Communication to pharmacy teams about patient safety plans 

The Regulation 28 report highlighted the lack of guidance/standards to ensure that the 
NHS and other providers of care inform community pharmacies of patient safety plans. 
We would very much welcome guidance/standards in this area. 

This is an active area in which the RPS continues to campaign. We believe  access and 
sharing of patient health records for community pharmacies is really important and 
recognising pharmacists have a legitimate need to access patient health records to 
improve patient outcomes for patients.  

An electronic copy of our policy and position statement is available from our website. 
https://www.rpharms.com/recognition/all-our-campaigns/policy-a-z/patient-health-records  

We have also published guidance around keeping patients safe when they transfer 
between care providers. This is available on our website.  
https://www.rpharms.com/resources/quick-reference-guides/keeping-patients-safe 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Need for national protocols 

We understand from your report that there has been implementation of a local protocol 
whereby the Cambridgeshire and Peterborough Foundation Trust’s Child and Adolescent  
Mental Health Service ensures that any pharmacy used regularly by their patients aged 
16-17 are (where appropriate) advised of relevant care plans. This sounds like an 
excellent initiative. We have also heard of other Child and Adolescent Mental Health 
Services (CAMHS) creating links with local community pharmacies.  

We believe that there is a need for more system leadership in this area noting that 
pharmacies are often the recipients of information. This regulation 28 report has been 
addressed to pharmacy organisations, and there is parallel need for organisations 
representing the NHS and CAMMHS services to make changes to prevent deaths.   

It would not be within the scope of our role to mandate local changes are adopted across 
the NHS and by other care providers, however we recognise the need for community 
pharmacies to be involved in the development of medication safety plans. If changes can 
be made by the relevant NHS organisations to ensure pharmacy teams are involved in 
this process, we will raise awareness of this amongst the pharmacy profession.   

Further considerations 

You may be aware of the Healthcare Safety Investigation Branch (HSIB). They are a 
government organisation that conducts independent investigations of patient safety 
concerns in NHS-funded care across England and are able to make safety 
recommendations to improve healthcare systems and processes in order to reduce risk 
and improve safety.  

If you would like to make a referral, their contact details are: HSIB, A1, Cody Technology 
Park, Farnborough, GU14 0LX 
them separately if you haven’t already done so. 

. You may wish to contact 

Thank you for bringing this to our attention and I hope our response has been helpful.  

Yours sincerely 

Professional Support Manager