Coroner’s Prevention Of Future Deaths Report

We have been made aware of a Prevention of Future Deaths Report which was issued by the Senior Coroner at St Pancras Coroner’s Court.

Wed 26th August 2020 The PDA

The failings, in this case, were so wide-ranging that the Coroner addressed the report to 13 different organisations and individuals including the GP, local CCG, NHS 111 and London Ambulance Service. We are circulating the report to our members who work in primary care because the identified failings had serious effects and have potential implications for the safe management of switching exercises.

We would also encourage pharmacists who may be involved at any stage in the provision of adrenaline pens to patients to reflect on the advice and support they could provide to patients to avoid similar deaths in future – we are therefore sharing this report with all PDA members.

We are circulating this report together with information from the Anaphylaxis Campaign aimed at ensuring all pharmacists administering flu vaccinations this year are prepared to deal with cases of anaphylaxis should they occur.


The Pharmacists' Defence Association is a company limited by guarantee. Registered in England; Company No 4746656.

The Pharmacists' Defence Association is an appointed representative in respect of insurance mediation activities only of
The Pharmacy Insurance Agency Limited which is registered in England and Wales under company number 2591975
and is authorised and regulated by the Financial Conduct Authority (Register No 307063)

The PDA Union is recognised by the Certification Officer as an independent trade union.

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