Oliver Billings

A m i c u s   H e a l t h   -   C l a r e   H o u s e
Clare House | Newport St | Tiverton | Devon | EX16 6NJ
01884 252337

A m i c u s   H e a l t h   -   B a m p t o n   S u r g e r y
Bampton Surgery | Barnhay | Bampton | Devon | EX16 9NB
01398 331304

January 2025

M Assistant Coroner Luisa Maria Nicholson
Office of the Coroner for Devon, Plymouth & Torbay

Subject: Response to Regulation 28 Report to Prevent Future Deaths – Oliver James Billings

Dear HM Assistant Coroner Nicholson,

Thank you for your Regulation 28 Report regarding the tragic death of Mr. Oliver James Billings. First and
foremost, we extend our condolences to Mr. Billings’ family. We are deeply sorry for their loss and are
committed to taking meaningful actions to prevent similar tragedies in the future.

We have carefully reviewed the concerns raised in your report, as well as the findings from and actions taken
following our internal investigation. We have taken steps to ensure that the lessons learned are fully
integrated into our processes and practices to safeguard against similar occurrences.

Response to Concerns:

1. Issuance of Subsequent Prescription Without Confirmation of Cancellation

We recognise the critical need for ensuring that a previously issued prescription has been fully cancelled
before generating a new one.

Our internal review identified that initially the action taken was correct in that when Prescription Clerk A was
asked by Mr Billings to change where the prescription was being sent, she informed him that he would need
to contact Pharmacy2u to ask them to release the prescription so that his preferred pharmacy could
dispense the prescription instead. This is in line with our policy and ensures that there is not a duplication of
prescription. The process to change a pharmacy once the prescription has been sent involves contacting
pharmacies directly and at present there is not a direct route for practices to easily do this. Where this
change is at patient request, rather than as result of an error, we put the onus back on the patient to arrange
this.

In usual circumstances a duplicate prescription should not be issued whilst there is still a live prescription in
process. We can see that in the case of Mr Billings, after he had been told to contact pharmacy2u by
Prescription Clerk A, Prescription Clerk B cancelled the first prescription through our clinical system. This did
not cancel the prescription for pharmacy2u as the prescription had already been downloaded. Prescription

 Clerk B then requested a duplicate prescription from a GP. It is not clear from the clinical system what
prompted the 2nd clerk to make this request as this was not recorded in the notes. More generally we might
see a follow up request if the patient has had difficulty contacting the nominated pharmacy and is worried
about running out of medication.

Our internal review identified that the cancellation request for the initial prescription did not take effect due
to the immediate download of the prescription by Pharmacy2U, which occurred within a minute of issuance.
This significantly limits the ability to cancel prescriptions promptly. Whilst we accept that a timely download
is important the speed that we see this occur from online pharmacy leaves no room for error/change of
request. Please see below timeline of prescription process.

Initial request processed by prescription
clerk
Prescription 1 signed by GP for 112 x
75mg venlafaxine tablets
Downloaded by P2U
Prescription Clerk A messaged patient
to contact pharmacy to redirect script
Re-requested by Prescription Clerk B
Prescription 1 cancelled by Prescription
Clerk B
Prescription 2 signed by GP for 112 x
75mg venlafaxine tablets
Downloaded by Superdrug
Dispensed by P2U
Dispensed by Superdrug
Claimed by Superdrug
Claimed by P2U

Time 

Date

12:46

27/11/2023

14:20
14:21

16:52
17:22

27/11/2023
27/11/2023

27/11/2023
27/11/2023

17:22

27/11/2023

17:47
17:49
11:21
12:04
17:25
23:25

27/11/2023
27/11/2023
28/11/2023
28/11/2023
28/11/2023
29/11/2023

Once the prescription has been downloaded by the pharmacy it is difficult to cancel, particularly with online
pharmacies who prefer email communication and can have long telephone waiting times. We feel that a
review of this system to allow practices to have the ability to cancel prescriptions in a more streamlined way
would prevent the need for the additional measures that the practice has put in place to safeguard against
duplication of prescriptions.

That said, we are committed to taking the steps we can, to prevent any future tragedies and we believe we
have taken all measures that are within our control. We have taken the following action to safeguard against
any future duplication of prescriptions:







Checked with the prescription and GP team to ensure that the cancellation of prescription is always
as a last resort.

Ensured that the prescription team, if cancelling prescriptions are conducting a dynamic risk
assessment to ascertain why this cancellation is required. As a further development a template is
being produced to support their thinking on this.

Sought assurance that patients, when requesting a change of pharmacy after prescription issue, are
given a prescription code and asked to contact the original nominated pharmacy to release back to
the spine. Informing them they can then take that code to any pharmacy to prescribe. We do this as

A m i c u s   H e a l t h
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A m i c u s   H e a l t h
B a m p to n

 a first line and have checked with the Devon ICB who are in support of this approach, likening it to
giving the patient responsibility by issuing them with a paper prescription. The issue with this often
arises when we add in the human factors of frustration, distress, and anxiety when the patient is
unable to contact the pharmacy themselves. This can be where the prescription team are prompted
to seek an alternative solution and request to cancel the prescription to reissue another.

Provided an alternative to cancellation and reissue in cases where the patient is worried about a
delay from the pharmacy. Namely asking clinicians to provide a ‘bridging prescription’ to cover the
days missing. This reduces the amount of medication being requested and therefore the risk. It also
avoids cancelling a prescription. It should be noted that this does however have an additional cost to
the patient and the NHS that would be avoided if we could easily cancel and reissue.

Should a prescription cancellation request be rejected electronically by the online pharmacy, then
the patient is advised to await delivery of said prescription as per their existing agreement with the
online pharmacy. Pharmacy2u recommends that the patient requests their new prescription 10 days
prior to running out of their existing supply.  Bridging prescriptions should not be necessary.
However, a bridging prescription of up to 5 days will be offered, where deemed suitable by the
authorising clinician following dynamic risk assessment.

Asked all prescriptions staff to email Pharmacy2U to communicate cancellations. This is under their
direction as their phonelines are not well manned and/or in high demand – They state in their
message that they prefer email. A call can take more than an hour to be answered, and it is not
sustainable for us to use our limited resource calling them, given their poor answering capacity.

Reviewed processes related to rejected prescription cancellation notifications within our clinical
system. This is an alert that will tell us within our clinical system if there has been a cancellation
request that has been rejected due to already being downloaded by the pharmacy.  To ensure that
these are monitored, and acted upon when required, a member of the prescriptions team is
assigned to review this each day.

Ensured all prescription staff are aware that they need to make certain all contact is documented in
the notes.









As you can see, whilst we have systems in place to overcome the inability to easily cancel a prescription this
is not straightforward and does have resource and cost implications for us and the wider system.

2. Swift Dispatch of Medication Preventing Error Correction

As noted above we understand that rapid dispatch of medications can limit the window for rectifying errors.
Unfortunately, it is not within our scope to change this. We would encourage Pharmacy2U and other online
pharmacies to explore the feasibility of implementing a more accessible cancellation process. We feel that
the automatic drawdown of prescriptions, which subsequently prevents cancellation should be reviewed to
reduce the additional administrative burden on general practice and reduce cost to the NHS in fees, because
of unnecessary medication dispensing.

As mentioned above, following this incident, our prescription team has implemented a monitoring system to
track and manage rejected cancellation requests more effectively.

3. Onus on Patients to Remedy Errors

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 As explained above we do ask the patient to contact the nominated pharmacy to ask for the release of a
prescription where the nominated pharmacy is being changed at the patient request.
Mr Billings was asked to contact pharmacy 2u and ask for the prescription to be returned to the spine
following the initial request from him to prescription clerk A that his prescription be sent to a different
pharmacy. There was no further action taken at that interaction and no request at that point for a duplicate
prescription. No error had occurred. It was the subsequent action from Prescription Clerk B that prompted
the duplication of prescriptions and whilst the correct action was not taken at this point to ensure the
prescription was cancelled there is no record that Mr Billings was asked to follow this up with Pharmacy2u.

Additional Measures Identified During Review:

Risk Assessments for High-Risk Medications: Patients identified as high risk of suicide and prescribed
medications such as will be flagged for closer monitoring. This includes regular reviews, risk assessments,
and ensuring prescriptions are limited to shorter durations to minimise potential misuse.

Improved Communication Protocols: We have eliminated the use of non-auditable messaging systems (e.g.,
screen messages) for clinical information to ensure transparency and accountability in prescription
management as we believe that this method was used for communication between Prescription Clerk B and
the GP who issued the second prescription.

We note that the immediate download of prescriptions by Pharmacy2U poses a significant challenge for
error rectification. We would like to see this issue reviewed by Pharmacy2U, other online pharmacy and
relevant regulatory bodies and changes implemented enhance patient safety. Specifically, we request easier,
more effective means of communication and cancellation. Other industries have online electronic
cancellation systems in place. It should be possible for the Pharmacy Industry to do this. We recognised this
will come at a cost to them but potentially a huge saving to the NHS in terms of risk and cost.

We deeply regret the circumstances surrounding Mr. Billings’ death and are committed to ensuring his
legacy drives meaningful improvements in patient care. We trust that these measures demonstrate our
commitment to addressing the concerns raised and our determination to prevent similar tragedies in the
future. Should you require further details or wish to discuss our response, please do not hesitate to contact
us. We also extend this invitation to the family of Mr Billings.

Yours sincerely,

Group Manager, on behalf of the Partners of Amicus Health Group

A m i c u s   H e a l t h
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A m i c u s   H e a l t h
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 A m i c u s   H e a l t h
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A m i c u s   H e a l t h
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HM Assistant Coroner, Luisa Maria Nicholson  
County Hall  
Topsham Road  
Exeter  
Devon  
EX2 4QD 

10th February 2025 

Dear HMC Nicholson, 

Inquest into the death of Mr Billings (2024-0656) - Response to Prevention of Future Deaths (PFD) report 

First and foremost, I would like to extend my deepest condolences to the family and friends of Mr Billings.  

I note the following matters of concern raised in the PFD report: 

(1)  That  a  subsequent  prescription  was  submitted  in  the  knowledge  that  the  first  was  cancelled  or  to  be 
cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that 
prescription before the subsequent prescription was issued. 

(2) That the swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow 
for mistakes to be noticed and/or remedied. 

(3) That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted. 

Response to concerns raised by HMC 

The  prescription  was  issued  by  the  surgery  directly  to  the  NHS  “spine”  –  the  secure  online  database  for 
electronic prescriptions - at 14:20 on 27 November 2023. We subsequently downloaded the prescription from 
the NHS spine at 14:21 on 27 November 2023.  

It is pertinent to note that electronic NHS prescriptions do not pass from a surgery to a pharmacy directly – 
they are sent from the surgery to the spine, and then from the spine to the pharmacy (and then only when 
the pharmacy checks the spine for any prescriptions that may have been assigned to it).  

The downloaded prescription was passed into our pharmacy system at 16:29, which allowed us to start our 
clinical processes (clinical check, labelling, assembly of the medicines, etc). 

Following receipt of the PFD report, we have manually checked the tracking details of this prescription on the 
NHS spine. Pharmacies are not expected to do this at the time of dispensing a prescription, nor would it be 
practical to do so. We can now see that the surgery sent a cancellation message to the spine at 17:22, just 
over three hours after the prescription was originally issued. 

Because we had already downloaded the prescription from the spine, the surgery’s attempted cancellation of 
the prescription from the spine was ineffective, and the surgery’s computer system would have indicated this 
to the surgery at the time, with a prompt to contact the pharmacy, which would have included our contact 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 details. In the absence of an attempt to contact us directly, we remained unaware of the surgery’s attempt to 
cancel the prescription. 

A  pharmacy  that  has  already  downloaded  a  prescription  from  the  spine  does  not  receive  an  electronic or 
automatic  notification  of  an  attempted  cancellation  by  the  prescriber.  This  is  how  the  software  for  the 
Electronic  Prescription  Service  was  designed  by  the  former  NHS Digital  (now  NHS  England, “NHSE”).  NHSE 
would be able to explain in more detail, but I believe that it was considered to be an unacceptable risk to 
patient safety if a prescriber was able to send a cancellation message directly to a pharmacy that relates to a 
prescription that has already been downloaded by that pharmacy, as to do so may give the prescriber a false 
sense of security that the cancellation would in all cases be effective; when the prescription could be at any 
stage of the dispensing process in the pharmacy and the medicines may have already been handed out or sent 
to the patient. The prescriber might then make further prescribing decisions based on the false assumption 
that the prescription has been cancelled, when it may not have been possible for the pharmacy to do so; and 
it would undoubtedly also place an unreasonable burden on pharmacy teams to constantly check for  such 
cancellation  messages,  as  well  as  placing  the  burden  of  responsibility  on  the  pharmacy  to  carry  out  the 
cancellation of the dispensing process when in many cases this would not be possible.  

The  cancellation  of  an  electronic  NHS  prescription  by  a  prescriber  after  it  has  already  been  issued  and 
downloaded by a pharmacy is an exceptional situation and, we consider, should be treated as such, and dealt 
with  by  way  of  a  personal  communication  between  the  surgery  and  the  pharmacy,  so  the  prescriber  can 
accurately  establish  the  dispensing  status  of  the  prescription  at  the  pharmacy  immediately  and  use  that 
information to guide their subsequent decisions.  

This is our understanding of how NHSE has designed the system: upon receiving a notification from the spine 
that its attempt to cancel a prescription has been unsuccessful, a surgery should manually contact the relevant 
pharmacy to discuss the intended cancellation, and the pharmacy’s contact details are displayed on the screen 
in the prescriber’s clinical system to enable them to make such contact. The relevant guidance on cancelling 
electronic 
https://digital.nhs.uk/services/electronic-prescription-
available 
service/cancelling-an-electronic-prescription 

prescriptions 

at: 

is 

In the absence of direct contact, as described above, regrettably I consider that there are no reasonable steps 
which  we  could  have  taken  to  have  established  that  the  prescriber  had  attempted  a  cancellation  of  the 
prescription on the spine after we had downloaded it. 

At 11:21 on 28 November 2023, we marked the prescription as “dispensed” on the spine, and the prescription 
was dispatched to the patient that day. The Royal Mail tracking information for the parcel is now unavailable 
due to lapse of time, but it was sent with a 48-hour service, so the earliest we expect it would have been 
delivered would have been 30 November 2023 (three days after it was prescribed). I understand the concern 
relating  to  the  swiftness  of  the  dispatch  of  the  medicines,  however  I  consider  that  our  dispensing  of  the 
prescription was done with reasonable promptness and was no more swift than would have been anticipated 
from any other pharmacy. 

The  NHS  Community  Pharmacy  Contractual  Framework  requires  that  NHS  medicines  and  appliances  are 
dispensed  by  registered  pharmacies  for  patients  on  demand  with  “reasonable  promptness”  (Exhibit  1).  I 
consider that it would be neither safe nor proportionate to introduce planned delays into pharmacy processes 
to allow a prescriber extra time to identify any post-prescribing concerns over and above those delays which 
are a natural part of a pharmacy’s existing processes. 

As I have shown with our timescales above, it took several hours for our clinical processes to be completed 
and for the medicine to be dispatched in this case. In addition, the dispensing pharmacy has a responsibility 
to conduct a clinical and professional check of prescriptions, an aim of which is to identify concerns and resolve 

 
 
 
 
 
 
 
 
 
 them with the patient and/or prescriber before dispensing. However, in this case, we could not reasonably 
have identified that the prescriber wished to cancel the prescription in the absence of  direct contact from 
them. 

I have no evidence of contact from the surgery or the patient in relation to this prescription. The PFD report 
states that a matter of concern is “That the onus was on Oliver to remedy the error when Pharmacy2U could 
not be contacted”. I consider that it is incorrect to state that we “could not be contacted”, as we at all times 
remained available to be contacted. As a matter of good business practice, we continually review our inbound 
contact capacity and performance to ensure that anyone who wants to contact us can do so quickly and easily, 
and we will always continue to monitor this.  

The NHS Directory of Services (https://digital.nhs.uk/services/directory-of-services-dos) is also available for 
healthcare  professionals  to  access  contact  details  for  healthcare  providers,  in addition  to  those  which  are 
available to the general public. 

In terms of actions that could be taken to prevent a recurrence of this situation: 

1. I consider that there may be a need for all prescribers to be reminded of the applicable guidance highlighted 
above and the importance of making direct contact with a pharmacy if they wish to cancel an electronic NHS 
prescription that has already been issued and downloaded by a pharmacy, and to follow the instructions in 
their clinical system when it alerts them that the electronic cancellation was ineffective. This may be a matter 
for the professional leadership body for GPs.  

2. I will also ensure that we continue to monitor our inbound contact channels and performance to ensure 
that we remain available for prompt inbound contact by anyone who needs to get in touch with us urgently 
for any matters.  

3.  I  have  also  discussed  this  case  with  our  senior  clinical  management  team  as  part  of  our  clinical  review 
process and we will continue to work internally and with our healthcare colleagues in other parts of the NHS, 
as well as with groups such as the Community Pharmacy Patient Safety Group, to continue to improve patient 
safety and share learnings across organisations. 

I am very sorry to have had to write to you in these circumstances and I again reiterate my condolences to the 
family and friends of Mr Billings. 

Yours sincerely, 

Superintendent Pharmacist, Pharmacy2U

Luisa Maria Nicholson, 
HM Assistant Coroner for Devon, Plymouth & Torbay 
Reference 18942608 

By email via: 

15th January 2025 

Dear Ms Luisa Nicholson, 

RE:  Regulation  28  Prevention  of  Future  Deaths  report  for  Mr  Oliver  James 
Billings, deceased. 

We are writing to you regarding the report into the death of Mr Oliver James Billings 
dated 28th November 2024. We would like to express our sincere condolences to the 
family of Mr Billings for their loss. 

The  Royal  Pharmaceutical  Society  (‘RPS’)  is  the  professional  leadership  body  for 
pharmacists  and  pharmacy  in  Great  Britain,  representing  all  sectors  of  pharmacy. 
Our role is to lead and support development of the pharmacy profession including 
the  advancement  of  science,  practice,  education  and  knowledge  in  pharmacy.  We 
transferred  our  regulatory  role  to  the  General  Pharmaceutical  Council  (‘GPhC’)  in 
2010 and they now regulate pharmacy and pharmacy professionals in Great Britain. 

In considering our response, we have sought input from our Expert Advisory 
Groups. 

We acknowledge the  conclusion from the inquest on 28th November 2024 that  the 
death of Mr Billings was due to suicide and that the medical cause of his death was a 
result of the toxic effect of venlafaxine.   

We also note the matters of concern in the report around: 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (1)  That a subsequent prescription was submitted in the knowledge that the first 
was cancelled or to be cancelled but that steps do not appear to have been taken 
or  be  able  to  be  taken  to  ascertain  the  status  of  that  prescription  before  the 
subsequent prescription was issued. 
(2)  That the swift dispatch of medication (whilst admittedly necessary in many 
circumstances) does not allow for mistakes to be noticed and/or remedied. 
(3)  That the onus was on Oliver to remedy the  error when Pharmacy2U could 
not be contacted. 

Regulation 28 reports provide an opportunity for learning and actions to be taken 
by organisations to prevent further deaths. The RPS notes from a study published in 
2023  looking  at  the  preventable  deaths,  that  one  in  five  coroner-reported 
preventable deaths involved medicines. Common medicines involved were opioids, 
antidepressants  and  hypnotics.  The  RPS  notes  that  coroners  expressed  concerns 
around  the  major  themes  of  patient  safety  and  communication,  including  minor 
themes of monitoring and communication between organisations. 1,2 

High risk medicines and vulnerable patients  
The  recently  published  Royal  College  of  General  Practitioners  and  RPS  Repeat 
Prescribing  Toolkit1,  advises  GP  practices  to  think  carefully  about  their 
arrangements for repeat prescribing of medicines. Patients should be offered regular 
and  careful  review  of  their  medicines  and  the  decision  to  prescribe  high-risk 
medicines should always be considered on an individual basis. 

The RPS recognises that general practice and community pharmacies should ensure 
that all high-risk medicines, and particularly opioids, antidepressants and hypnotics, 
are treated carefully where they are to be prescribed as a repeat medication. The GP 
practice, the pharmacy and the patient all need to be clear about the arrangements 
for ordering and monitoring of such medicines as well as frequency of and purpose 
of a thorough, structured medication review.1 This may include discussions with the 
patient around suitability for accessing their prescribed medication via a  distance-
selling online community pharmacy.  

The RPS would suggest to the coroner that this prevention of future death report is 
also  shared  with  the  Royal  College  of  General  Practitioners  for  wider  shared 
learning. 

Communication between healthcare providers   
The RPS notes from the coroner’s report that the cancellation of the EPS prescription 
by  the  GP  practice  to  the  distance-selling  online  community  pharmacy  was 
unsuccessful  and  that  the  GP  practice  was  unable  to  get  in  contact  with  the 
pharmacy.    We  note  that  the  report  didn’t  include  details  around  attempts  at 

1.  Royal College of General Practitioners and RPS, 2024. Repeat Prescribing Toolkit [Online]. Available from: 

2. 

https://www.rpharms.com/resources/repeat-prescribing-toolkit [Accessed 11 January 2025] 
France, H S., Aronson JK, Heneghan C. et al., 2023. Preventable Deaths Involving Medicines: A Systematic Case Series of 
Coroners' Reports 2013-22. Drug Saf [Online], 46. Available from: https://link.springer.com/article/10.1007/s40264-
023-01274-8 [Accessed 15 January 2025] 

 
 
 
 
 
 
 
 communication  from  the  GP  practice  to  the  distance-selling  online  community 
pharmacy. 

The RPS believes that  the  onus should be on the prescriber and not the patient to 
contact  the  community  pharmacy  to  discuss  next  steps  in  the  event  of  an  EPS 
prescription cancellation failure.  

The RPS recognises that there needs to be clear  routes of communication between 
the  GP  practice  and  the  community  pharmacy  (including  distance-selling  online 
community pharmacies) to manage situations where EPS prescription cancellations 
have been unsuccessful.  

NHS  Digital  have  issued  guidance  on  robust  processes  on  EPS  for  healthcare 
providers.  

Digital Functionality of EPS 
We  have  sought  further  information  on  the  EPS  system  from  our  Digital  Expert 
Advisory Group on the issue of EPS prescription cancellation.  

An  EPS  Prescription  Tracker  tool  is  available  to  all  NHS  professionals  who  have  a 
smartcard (which usually includes all prescribers and dispensers of EPS prescriptions) 
to allow them to check the status of an EPS prescription. The sharing of information via 
EPS between community pharmacies needs further consideration.  

We  understand  that  there  is  currently  future  development  underway  for  a  “Clinical 
Tracker” for EPS which will provide Health Care Professionals access to a patient’s EPS 
history, detailed products and dispensed status.  

The RPS would suggest to the coroner that this prevention of future death report is 
also shared with NHS Digital for wider shared learning and comment on EPS.  

Dispensing and supply of medicines from a community pharmacy  
The  coroner’s  report  refers  to  the  ‘swift  dispatch  of  medication  (whilst  admittedly 
necessary  in  many  circumstances)  does  not  allow  for  mistakes  to  be  noticed  and/or 
remedied’. It is worth noting that under the NHS Community Pharmacy Contractual 
Framework  Essential  Service  –  Dispensing,  there  is  a  contractual  obligation  for 
community  pharmacies  in  England  to  dispense  medication  for  patients  with 
reasonable  promptness.  Medicines  optimisation  is  about  ensuring  that  the  right 
patient receives the right medicine at the right time.  All assessments of the clinical 
appropriateness of a medication by a prescriber should be complete before issuing 
the  prescription,  therefore  the  subsequent  benefits  of  a  safe  and  timely  supply  of 
medicines would outweigh risks of supplying medicines efficiently. 

1.  Royal College of General Practitioners and RPS, 2024. Repeat Prescribing Toolkit [Online]. Available from: 

2. 

https://www.rpharms.com/resources/repeat-prescribing-toolkit [Accessed 11 January 2025] 
France, H S., Aronson JK, Heneghan C. et al., 2023. Preventable Deaths Involving Medicines: A Systematic Case Series of 
Coroners' Reports 2013-22. Drug Saf [Online], 46. Available from: https://link.springer.com/article/10.1007/s40264-
023-01274-8 [Accessed 15 January 2025] 

 
 
 
 
 
 
 
 
 
 
 
 Thank you for highlighting your concerns in this prevention of future death report.  
We will consider how we can continue to raise awareness of these important issues 
through  our  future  communications  and  engagement  with  the  wider  pharmacy 
sector.  We  will  also  raise  these issues  with  our  colleagues at  the professional  and 
representative bodies for pharmacy as they also play an important role in providing 
advice and support to the pharmacy professions. 

Please don’t hesitate to contact us if you need anything further. 

Yours sincerely, 

Chief Executive Officer  
Royal Pharmaceutical Society  

1.  Royal College of General Practitioners and RPS, 2024. Repeat Prescribing Toolkit [Online]. Available from: 

2. 

https://www.rpharms.com/resources/repeat-prescribing-toolkit [Accessed 11 January 2025] 
France, H S., Aronson JK, Heneghan C. et al., 2023. Preventable Deaths Involving Medicines: A Systematic Case Series of 
Coroners' Reports 2013-22. Drug Saf [Online], 46. Available from: https://link.springer.com/article/10.1007/s40264-
023-01274-8 [Accessed 15 January 2025]