Regulation 28 report to prevent future deaths – remote prescribing

This is the latest in a series of articles highlighting cases where better prescribing or dispensing related activity might have prevented harm.

Thu 8th April 2021 The PDA

This case involved remote prescribing – an area where the PDA has long advised members to be extremely cautious due to the associated risks.

The PDA receives regular questions from members regarding the setting up of online pharmacies as prospective business ventures or because they are working in an online pharmacy company and require support with an incident.

This report involved the sad case of a former registered healthcare professional who became dependent on codeine following prolonged treatment for chronic pain. When her GP practice decided that they could no longer provide further prescriptions for Zapain unless she agreed to attend the surgery to discuss the matter, the patient resorted to sourcing medication (Zapain and a variety of other prescription medicines) via numerous online pharmacies and unknown doctors. None of these other providers contacted her GP at any time to ascertain the safety or appropriateness of them providing opiates, psychotropic drugs, and beta-blockers to the patient.

The patient died due to excess consumption of codeine.

We would urge all members to read the coroner’s report and to consider the following questions about their organisations:

General Practice

  • Are there patients who have been on long-term opiate medicines with questionable ongoing indications?
  • Do practice staff regularly monitor opiate prescription orders for over/early ordering and escalate?

Online pharmacies

  • Could my organisation have been one of the ones providing this patient with POMs without informing her GP?
  • What risk management measures do we have in place to judge whether providing POM medicines without access to the patient’s notes is safe?
  • Is it possible for patients to order POMs prescribed by me without ever speaking to me or any other clinician?
  • How do I assure myself that a patient is safe when prescribing POMs which require monitoring and follow-up?

You can read the Coroner’s report here: Coroner’s Regulation 28 Report

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The Pharmacists' Defence Association is an appointed representative in respect of insurance mediation activities only of
The Pharmacy Insurance Agency Limited which is registered in England and Wales under company number 2591975
and is authorised and regulated by the Financial Conduct Authority (Register No 307063)

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