Coroner Elizabeth Wheeler last week (June 19) warned the RPS that its guidance “does not seem to address” pharmacists’ differing interpretations of prescriptions after a diabetes patient died.
The assistant coroner for Cheshire said that 56-year-old Simon Hockenhull “struggled to control” his diabetes since he was diagnosed in 2017.
She added that “his diabetes and [its] poor management” led to gastro-intestinal issues, which in turn “made him more prone to contracting infections and more vulnerable when he did contract them”.
Read more: Coroner: Patient overdoses after ‘excess’ bank holiday diazepam and codeine scripts
Over 2024, Hockenhull‘s “diabetic control significantly worsened” and he was admitted to intensive care “multiple times…as a result of diabetic ketoacidosis”, she said.
He was found “collapsed but breathing” at his home on December 5 and his brother called emergency services but he had died “by the time paramedics arrived”, she added.
“Hockenhull died as a result of contracting lobar pneumonia, contributed to by his underlying diabetes and diabetic gastro enteropathy that materially reduced his resilience,” she found.
“Inconsistently defined”
Wheeler raised concerns that “some diabetic medications and devices have a life span of 14 days”, meaning that “when two are prescribed they therefore amount to a 28-day supply”.
“I have heard that this can cause problems as there are some pharmacists who interpret a 28-day supply as a ‘month’,” she said.
“It can therefore be challenging to obtain a further prescription within the same calendar month,” she added.
Read more: Coroner: Young man overdosed after receiving double script from P2U and Lloydspharmacy
“For patients who already have a complex relationship with their medication and monitoring regime, the challenges this causes can mean that they then do not take their medication as consistently as they need to,” she said.
And for patients with diabetes “this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis”, she added.
“At the heart of the issue seems to be that a ‘month’ is being inconsistently defined – sometimes it means 28 days, sometimes it is a calendar month,” she stressed.
“Does not address the issue”
Wheeler warned that the RPS’s “repeat prescription toolkit”, which was published in October, “does not seem to address this issue”.
“It may be that prescribers and dispensers are unaware of this issue,” she said.
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She found that the RPS should take action “to prevent future deaths”, adding that it must respond to her report within 56 days.
The RPS today (June 23) told C+D that it will respond directly to the coroner’s report and is not in a position to issue any comments before then.
Prescription drug deaths
Meanwhile, a senior coroner found in November that a 78-year-old woman overdosed after being given excess diazepam and codeine ahead of an Easter bank holiday weekend.
After a seven-month investigation, the coroner raised concerns that there are “no measures relating to longer bank holiday periods” such as Easter when early prescriptions are issued because pharmacies are “likely to be closed”.
Read more: Coroner: Patient overdosed after pharmacy ‘welfare concern’ missed
And in December, another coroner raised concerns around the death of 22-year-old Oliver James Billings, who died by suicide after a “prescribing error” left him “suddenly in possession” of hundreds of prescription drugs.
She said that Billings acquired the additional tablets “due to a prescribing error where he changed his choice of chemist from an online pharmacy – Pharmacy2U – to a local [Lloydspharmacy] store”.
