Sheridan Pickett

Minister of State for Health (Secondary Care)  

39 Victoria Street  
London  
SW1H 0EU  

11 June 2025  

Our ref: 

HM Assistant Coroner Jyoti Gill  
Coroner’s Court   
1 Mount Tabor Street   
Stockport  
SK1 3AG  

By email: 

Dear Ms Gill,   

Thank you for the Regulation 28 report of 19th March 2025 sent to the Secretary of State / 
the Department of Health and Social Care about the death of Mr Sheridan Tate Pickett. I am 
replying as the Minister with responsibility for medicine regulation and prescribing.        

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Pickett’s 
death and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.   

The report raises concerns over the importance of adhering to clear guidelines for online 
prescribing and information sharing between private providers and NHS services.  

When used appropriately, online prescribing provides a valuable route for patients to access 
their  prescription  medicines  which  takes  pressure  off  GP  practices.  Prescribers,  whether 
working for the NHS or privately, in-person or remotely, are accountable for their prescribing 
decisions. They are expected to take account of appropriate national guidance. Prescribers 
should work with their patient and decide on the best course of treatment, with the provision 
of the most clinically appropriate care for the patient always being the primary consideration. 
In addition to the duty of the prescriber, patients themselves must be honest when providing 
information  to  an  online  prescriber  so  that  they  receive  advice  and  medicines  which  are 
appropriate for them and so that risks can be managed.   

The  General  Pharmaceutical  Council  (GPhC)  sets  out  the  precautions  to  put  in  place  if 
certain medicines requiring additional safeguards are to be supplied online. These include 
but are not limited to assuring that the person has provided the contact details of their regular 
prescriber, such as their GP, and their consent to contact them about the prescription; and 

  
  
  
  
  
  
  
 
  
  
  
   
   
   
 that the prescriber will proactively share all relevant information about the prescription with 
other health professionals involved in the care of the person (for example their GP). Further 
information  on  this  can  be  found  here:  Guidance  for  registered  pharmacies  providing 
pharmacy services at a distance, including on the internet.   

The  above  guidance  was  updated  (February  2025)  in  response  to  concerns  relating  to 
unsafe prescribing and supply of medicines online and includes strengthened safeguards 
designed to prevent people from receiving medicines that are not clinically appropriate for 
them and may cause them harm. Specifically, the February 2025 guidance sets out what to 
include  in  a  risk  assessment  when  prescribing  services  are  involved,  this  includes 
considering how the diverse needs of people using pharmacy services are identified, and 
how  staff  get  users’  valid  consent  (for  example,  how  staff  assess  the  mental  capacity  of 
users).  The  February  2025  guidance  states  that  “The  risk  assessment  should  cover  the 
whole service, including the medicines and treatments which are provided”.  

The  guidance  also  sets  out  strengthened  safeguards  that  should  be  in  place  before 
supplying certain medicines online. It states that a prescriber should not base prescribing 
decisions on the information provided in a questionnaire alone.   

To  ascertain  further details  about  procedures  followed  by  the  provider  that  prescribed  Mr 
Pickett’s medication, you could directly approach the General Medical Council (GMC) and 
the  General  Pharmaceutical  Council  (GPhC)  who  may  have  responsibility  for  their 
regulation.   

The report gives no indication that the online provider acted unlawfully but in situations where 
this could apply, the GPhC and other professional regulators, the Care Quality Commission 
and  the  Medicines  and  Healthcare  products  Regulatory  Agency  have  the  powers  to 
investigate and take action against prescribers, products and suppliers who do not comply 
with legislation and national guidance.  

In  your  report,  you  raise  concerns  that  there  are  no  current  guidelines  governing 
communication and information sharing between private providers and NHS providers. The 
following guidance, Hospital discharge and community support guidance - GOV.UK states 
that:  

‘health and care professionals (such as clinicians and social workers) should share 
appropriate and accurate information early to support a safe and timely discharge, for 
example, about medication (including whether medication has changed since hospital 
admission)  and  immediate  support  needs,  including  transport  and  equipment 
required. They should also seek information from those involved in the patient’s care 
prior to admission early on so this can be used to inform discharge planning.  

Sufficient and accurate information should be provided on discharge to enable any 
providers of onward care and support to meet the needs of the person transferred to 
them.  This  includes  details  about  the  person’s  condition,  information  about  the 
person’s  medications,  whether  a  personalised  care  and  support  plan  or  personal 
wellbeing plan has been updated or established, and arrangements to have their care 
and support regularly reviewed to support their recovery.’   

 I can confirm this does apply to communication with private as well as NHS providers.  

 Lastly, I would like to assure you that we are committed to tackling suicide as one the biggest 
killers in this country. As part of this, the 8,500 new mental health workers we will recruit will 
be trained to support people at risk, to reduce the lives lost to suicide.   

We are also committed to continuing to deliver the cross-sector Suicide Prevention Strategy 
for England published in 2023.  This identifies a number of groups for tailored or targeted 
action at a national level, including people in contact with mental health services.   

I hope this response is helpful. Thank you for bringing these concerns to my attention.    

Yours sincerely,   

MINISTER OF STATE FOR HEALTH