Jamie O'Connor
21 Oct 2021 · Coroner Dianne Hocking · Leicester City and South Leicestershire
This report repeats 5 earlier warnings, and was raised again 1 time later. See the linked reports.
The coroner's concerns
1. uncontrolled prescribing of contraindicated drugs
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom”
2. lack of GP awareness of prescribed medication
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed”
3. remote prescribing without clinical assessment
“There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed”
4. inadequate screening questionnaire
“There was a very limited questionnaire about the history of the person requesting the drugs”
5. direct-to-patient drug specification
“Persons requesting the drugs were able to ask specifically for which drug they wanted before contact with the prescriber”
6. insufficient regulatory oversight
“By virtue of where the company prescribing the drugs was registered there was limited regulation”
Linked reports
Identical hazardConfidence 0.95 · high
Earlier report
“There is evidently no central database of all prescription errors so there can be no central monitoring of such errors and no means of determining trends or particular repeat errors.”
This report
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom.”
Closely relatedConfidence 0.85 · high
Earlier report
“He prescribed Citalopram, Tramadol, Methadone, Diazepam and Sodium Valproate on 10th to a new patient without seeing him, although probably in possession of old medical records from previous stay in prison, but not those from his GP related to the period before detention in prison”
This report
“There was no necessity for a face to face consultation with the person requesting the drugs and the prescriber before drugs were dispensed;”
Identical hazardConfidence 0.90 · high
Earlier report
“(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.”
This report
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“Permitting the patient to”
This report
“There was a very limited questionnaire about the history of the person requesting the drugs.”
Identical hazardConfidence 0.95 · high
Earlier report
“There is no single database that allows a prescribing clinician to identify what prescription only medication has already been prescribed to any particular patient.”
This report
“There is no central tracking system or central database to record what each person has been prescribed and dispensed and by whom.”
Closely relatedConfidence 0.90 · high
This report
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed”
Later report
“The delay of information relating to what has been prescribed to an individual being sent to the GP surgery by voluntary and NHS organisations.”
Responses
2021-0363-Response-from-CQC_Published.pdf ↗· General Medical Council
Stated action
“We are also aware that our regulatory partners, including MHRA and the GPhC, share our concerns about the lack of regulatory oversight in this area.”
2021-0363-Response-from-DHSC.pdf ↗· NHS England
Stated action
“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.”
2021-0363-Response-from-GMC_Published.pdf ↗· Department of Health and Social Care
Stated action · February 2021
“we published updated guidance for doctors on prescribing in February 2021. This now places a greater emphasis on following the principles of good practice regardless of the medium through which a consultation is taking place, face to face or online.”
2021-0363-Response-from-GPC_Published.pdf ↗· Care Quality Commission
Stated action
“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”