Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of GP awareness of prescribed medication
The earlier warning
Richard Breatnach · 15 Sept 2016 · Veronia Hamilton-Deeley, Brighton and Hove
“(3) There was no evidence that the prescriber made any effort to contact Mr [name redacted] GP to find out if the answers that he gave were true.”
What was promised
Stated action 1 · response to Richard Breatnach (15 Sept 2016) · stated timescale: 1st December 2016
“NHS England will use this learning to inform its Digital Strategy. We will also include advice to General Practitioners about Special Patient Notes, which are used within the integrated urgent care software so alerts can be set up for NHS 111 call handlers and out of hours general practitioners when they access a particular patient record as part of the Pharmacy Urgent Medicines Supply service being introduced from 1st December 2016.”
Stated action 2 · response to Jamie O'Connor (21 Oct 2021) · stated timescale: none stated
“we expect pharmacy owners to: - Make sure that their website and the websites of companies they work with are arranged so that a person cannot choose a prescription only medicine and its quantity before there has been an appropriate consultation with a prescriber”
Stated action 3 · response to Jamie O'Connor (21 Oct 2021) · stated timescale: none stated
“The Department is working with other healthcare regulators including the General Medical Council and their equivalents in Scotland, Wales and Northern Ireland in the area of digital healthcare provision. As a result, a review of the UK's legislative position was undertaken and gaps identified. These included cases involving inappropriate prescribing and a lack of checks with the patient's GP before prescribing.”
2 further stated actions are listed on the full chain page.
What recurred
- 21 Oct 2021 · Jamie O'Connor · Dianne Hocking · Identical hazard · confidence 0.90 (high)
- 4 Nov 2024 · Neil Yates · Anita Bhardwaj · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Jamie O'Connor · 21 Oct 2021
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed”
Later · Neil Yates · 4 Nov 2024
“The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.”
What happened next
No web check of the stated actions has been published for this chain.