Richard Breatnach
15 Sept 2016 · Coroner Veronia Hamilton-Deeley · Brighton and Hove
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. online medication application
“Mr [name redacted] (and anybody else) is able to apply online for medications”
2. unverified online medication application
“applying online, if the application form is not thoroughly checked , allows the applicant to lie or give false or misleading answers to critical questions which is what Mr [name redacted] did”
3. lack of GP verification
“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”
4. inappropriate prescribing of Dihydrocodeine
“Prescribing Dihydrocodeine, a potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice”
5. excessive Dihydrocodeine prescription
“The amount of Dihydrocodeine prescribed appears to be excessive”
6. inappropriate indication for Dihydrocodeine
“understand from the evidence that | heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr [name redacted] gave for asking for this medication”
Linked reports
Identical hazardConfidence 0.90 · high
This 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.”
Later report
“There is no requirement to contact the GP of the person requesting drugs to let them know what has been prescribed.”
Responses
2016-0330-Response-by-NHS-England.pdf ↗· NHS England
Stated action · 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.”