Thanks for the link.
I agree that this should be criminal.
Unfortunately a finding that care "fell substantially below" accepted standards is not the same thing as proving a criminal offence.
In England and Wales, criminal liability generally requires proof beyond reasonable doubt. Civil liability (such as medical negligence) only requires proof on the balance of probabilities, that something was more likely than not.
That difference matters enormously.
The report's findings may be highly relevant to GMC proceedings, NHS contractual action, CQC enforcement, and civil negligence claims. None of those require the same standard of proof as a criminal prosecution.
For a criminal case, prosecutors would need to prove not just poor practice but the elements of a specific offence.
If a patient had died and the death could be linked to the prescribing practices, prosecutors might examine gross negligence manslaughter. The threshold is extremely high: negligence must be so serious as to be truly "gross".
If there were evidence that clinicians knowingly ignored obvious risks or consciously disregarded their duties, prosecutors might consider offences of wilful neglect. Mere incompetence, poor judgment, or substandard practice is not enough.