Coroner highlights the role of poor medicines review in death of patient

The BMJ recently reported on the sad death of a patient who died of a tramadol overdose. The patient was found to have significant quantities of unused repeat medicines in their home.

Fri 21st August 2020 The PDA

The patient was 84, had dementia and had been supplied with 100 tramadol capsules per month for an extended period of time (learn more).

The coroner, Geoffrey Collins has demanded that Simon Stevens, Chief Executive of the National Health Service, take action to ensure that GPs monitor repeat prescriptions properly.

The issue of poor monitoring of repeat prescriptions in general practice has been a long-standing one with many associated risks, particularly for vulnerable patients. It is therefore good to see that the contribution which practice-based pharmacists can make to medicines safety and patient care has been recognised by NHSE and supported via the clinical pharmacist in general practice and PCN DES pharmacist programmes.

We trust that Simon Stevens will engage with GPs to ensure that they do everything possible to ensure that their systems and processes include a regular and meaningful review of prescribed medicines, wherever possible with the support of practice pharmacists.

Priority work for PCN pharmacist teams this year will include structured medication reviews for a number of patient groups including those at risk of developing a dependence on opiate analgesics. However, this is not the full story.

There is another group of pharmacists who have a crucial role to play in keeping medicines supply safe, and these are the pharmacists working in community pharmacy who oversee the supply of dispensed medicines to patients. One wonders what safeguarding is in place for patients like this vulnerable elderly gentleman living with dementia. Do they have a carer? If not, how do they get their medicine and who orders it on their behalf? Are they signed up for a ‘Repeat Prescription Ordering Service’? How are dispensing pharmacies ensuring that the medicines supplied to these patients are safe and appropriate on each occasion?

Sadly, the PDA has heard from colleagues of a number of cases where community pharmacies have continued to order, dispense and deliver prescription medicines to patients who were lying inside their homes deceased. In one case, this was for several months. We also receive feedback from pharmacists that some employers incentivise item growth and that any downward fluctuations in prescription items affect pharmacist bonuses. This situation can only increase the pressure to supply and claim for medicines which may be contrary to the best interest of the patient; business owners and shareholders are the only beneficiaries in such situations.

We believe the coroner could have gone further and required Simon Stevens to take action in two other areas:

  • Ensuring that pharmacy contractors who prioritise prescription item volume above all other considerations are identified and meaningful action is taken against them.
  • Radically altering the current community pharmacy reimbursement model which perversely acts to support and incentivise the supply of ever-increasing volumes of prescription medicines leading to the squandering of vast amounts of NHS resources and (at its worst) the death of vulnerable patients.

Imagine a model where a network of community pharmacists across the country were rewarded for providing episodes of care to patients from community pharmacies – with the bulk of reimbursement being dependent on supporting patients to self-manage and live well with their health conditions (e.g. keeping BP within the target range for their condition, being able to live a relatively independent life despite dementia due to regular support and help to avoid the dangerous accumulation of medicines).

In this model, dispensed medicines would be the means to an end of effective pharmaceutical care, not the prime objective-driven purely by the urge to maximise profits.


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