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recurance

Matthew Power

26 Jun 2023 · Coroner Susan Ridge · Surrey

The coroner's concerns

  1. 1. pending prescription mistakenly issued

    “when one doctor ends a repeat prescription on EMIS, it remains in the 'pending' Medication Management box of the doctor to whom it was originally sent. Creating the risk, as in this case, that as a pending prescription it is actioned and issued instead of cancelled”
  2. 2. grouped prescription entries obscure dosage

    “EMIS system appears to group prescriptions into the amount prescribed rather than simply recording when a prescription is issued”
  3. 3. difficulty retrieving prescription history

    “to interrogate the EMIS system in order to ascertain what had actually been prescribed, issued and when, was a challenging task; it had taken 3 GPs and the in-house pharmacist to conduct the review”

Responses

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

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