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EPS must flag urgent prescriptions, says coroner after patient death

Coroner: A missed EPS prescription could create a risk of future deaths
Coroner: A missed EPS prescription could create a risk of future deaths

A coroner assessing the death of an elderly patient has called for electronic prescription service (EPS) systems to be updated to "communicate clinical urgency".

In her report into the death of 83-year-old Douglas Hodges, Heidi Connor, assistant coroner for Nottinghamshire, noted that Professor Hodges had been prescribed antibiotics by his GP.

The prescription was issued via EPS on March 27 and the GP expected it to be "actioned urgently" and delivered to Professor Hodge's home by Well Pharmacy in Chilwell, Nottingham, "that day or the day afterwards", Ms Connor said.

However, while the prescription was downloaded by the pharmacy, "the paper token has never been found", Ms Connor summarised in her report on October 12.

She concluded it had been “mislaid or accidentally disposed of”, with the result that Professor Hodges’s antibiotics were “never dispensed”.

Professor Hodges died in hospital on April 3 from multiple organ failure and systemic sepsis. Ms Connor stressed it is “unlikely” that had he received the antibiotics prescribed, “the outcome would have been different”.

However, she added that “a missed prescription could create a risk of future death in a different case”.

The coroner’s recommendations

Ms Connor said that “action should be taken” and stressed that Well, NHS Digital and Cegedim – whose system was used in the Well branch in question – “have the power to take such action”.

Addressing NHS Digital, she pointed out there is currently “no way of communicating clinical urgency between prescriber and pharmacy staff at the time the prescription is downloaded”.

She noted an NHS Digital survey where pharmacists “made clear this is the change they most want to see”. Professor Hodges’s case “makes the case for this change very clearly”, she stressed.

“I consider there is a real risk of future deaths if this is not addressed,” Ms Connor added.

She also called upon Cegedim to review and clarify the ‘help’ section of its software, which “suggested the red exclamation mark system was available, [although] this was not being used”. This “clearly led to confusion”, she added.

Addressing Well Pharmacy, Ms Connor said she is aware the multiple is trialling a new system (see below) and asked what the intention is after the trial period ends, as well as how the company proposes to reduce the risk of missed prescriptions.

Well, NHS Digital and Cegedim respond

Well superintendent pharmacist Janice Perkins said the multiple is “taking the incident very seriously” and has conducted a “thorough investigation to identify what happened”.

Five steps are being taken to minimise the risks in the future, Ms Perkins said, including writing to all clinical commissioning groups highlighting that prescriptions sent urgently are not currently flagged in the EPS system, and sharing a summary of the incident and learnings with all Well branches.

Every Well branch is also participating in a trial whereby “acute prescriptions and walk-ins are downloaded individually when the patient presents”, while “all other prescriptions are downloaded at set times, three times a day”.

“The trial is still ongoing and we will continue to introduce the new way of working across our stores,” Ms Perkins added. “A full review will take place in May 2018.”

Richard Ashcroft, NHS Digital programme director for digital medicines, stressed that Ms Connor had made clear that EPS was “not a contributing factor in Professor Hodges’s death”, and had instead asked the organisation to look at “how the system can be adapted to communicate clinical urgency”.

“We are working closely and collaboratively with all parties to develop a solution,” Mr Ashcroft said. “We are now expediting this project to find both short-term workarounds and longer-term solutions.”

Refering to Ms Connor's scrutiny of the 'help' section of its software, Cegedim told C+D its help files include “extensive information” about the “full range of functionality available within the software, but not all functionality is available at every site”.

“Cegedim Rx cooperated with the request of the coroner and removed the relevant section from the help file,” a spokesperson said.

What do you make of the coroner's recommendations?

Andrew Paxton, Community pharmacist

the easiest thing to do is for the GP to ring the pharmacist, but they are far too up their own jaxies to do that!!

Joan Richardson, Locum pharmacist

At present there is no way of knowing whether any prescription, urgent or otherwise, is on the spine awaiting downloading unless you happen to connect to the spine to look for prescriptions.  Most pharmacies connect to the spine several times a day to see if there are any prescriptions waiting..  A telephone call from the surgery saying that there is an urgent prescription would mean that the pharmacy would connect to the spine to look for it specifically.

This is the same situation as arises during surgery times when a patient arrives in the pharmacy expecting their prescription to be ready for collection because the GP sent it while they were in the surgery.  Unless the pharmacy has connected to the spine while the patient is on their way then the pharmacy is not aware that there is a prescription for that particular patient awaiting dispensing.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Does anyone know if the GPhC made any comments or decisions regarding this? 

Ilove Pharmacy, Non Pharmacist Branch Manager

I’m surprised the GPhC haven’t struck off the pharmacist 

Sachin Badiani, Pharmacy owner/ Proprietor

Local surgery phoned up an urgent prescription. They asked us if we could deliver today. Once we agreed that it could be delivered today, the details were passed for the prescription. The patient received their medicine.

This patient is also an ETP nominated and her normal monthly scripts came at the same time.

We delivered because the surgery contacted us (two way communication as described in previous comments). You can not solely rely on ETP and sending through. Staff at the pharmacy need to be alerted of pending urgent prescription.

I am surprised there is no mention of "recommendations" for the GP surgery to implement, even if pharmacy is the last one in the queue before the patient.

Gerry Diamond, Primary care pharmacist

Good communication is key and if I do an urgent prescription then I usually go to the chenist hand it to them personally and ask them to deliver. And t.ey graciously deliver asap, so pharmacists have been unfairly tarnished in my opinion,

Valentine Trodd, Community pharmacist

Maybe the coroner, like most patients, assumed that delivery is an essential service funded by the DoH, rather than a courtesy provided at the contractor's expense? Also how typical that pharmacy receives ALL the blame, with no mention that the GP should have followed up and made the pharmacy aware of his expectations.

Shaun Steren, Pharmaceutical Adviser

The individual case is tragic and should be questioned according to the particular facts. As a general comment, I find that in most pharmacies I work the branch has a super-deferential relationship with both patients and GP surgeries. They will attempt to deliver a level of service that cannot practically be delivered and never question the demands put on them. I’m quite happy to tell people they cannot have what they demand, as it is not practically possible at that particular point in time. I’m immune to the abusive, ignorant or disrespectful response I often receive. If you want something very specific done within a particular timeframe, you need to give me clear and advanced notice, then I will decide (conservatively) whether I can meet that request. 

You can’t have the quality that people demand in the quantities demanded. I sacrifice the quantity so as not to diminish the quality. Are people happy with this? No. So why am I, and others, willing to do this, whilst the majority are not? Well, I’m coming to the end of my career and I will not blemish decades of quality practice by making critical errors in the attempt to meet impossible demands. It is easy for me to say this because of course - I am at the end of my career. You can refuse to offer any future bookings - I can afford to not care.

I feel sorry for those who might have many more years of hellish work environments ahead, each day risking critical error to meet these impossible demands. You will be blamed when something goes wrong and the context of the work environment will not be considered - this I can assure you. You need to ask yourself: Are your own quality standards higher than those who employ you? What risks are you willing to take to meet the (impossible) demands of others? How do these factors intersect with your need to make a living? 

Reeyah H, Community pharmacist

‘Expected’. Too much is ‘expected’ of us. If the patient was so poorly, why didn’t the Dr deliver it, or call a family member to take it to the patient. We are not psychic! We have so much of this - with scripts sent last minute and it’s ‘expected’ that we will deliver. 

R Patel, Community pharmacist

Not sure of the time the prescription was sent. Quite often we have a foot note by a dr on an eps script received after 6 , on a Friday, ‘Pharmacy to deliver ’. We have then the run around of contacting the patient who then has to arrange for collection or I have to deliver on my way home as the dr has shut surgery phones down and thinks he has done his job!

Chandra Nathwani, Community pharmacist

It is indeed a sad incident of a "preventable" problem. It has already been mentioned above that the GP should have communicated to the pharmacist "Directly" as to the nature of the emergency and the antibiotics that required to be delivered. Relying completely on EPS would not address the situation completely because the coronor assumes that EPS is a perfect system. All day today I have had a power cut due to Southern Electricity Supply station cabling burnt due to overload. I had  NO EPS or Power or Heating all day so even if the script was flagged with "bells and whistles", it would have sat in the cloud somewhere. Three years ago, I had the main EPS server down due to hard disk failure, and that too meant no access to EPS. There is nothing to say that if BT dug up the road EPS would not be affected. The resposibility lies with the GP and the coronor has not addressed that in the news story above. The solutions suggested can help but DO NOT adress the issues I have had described above and perhaps a recomendation should be made to the GMC/BMA also to ensure that urgent messages like these are passed directly to the Pharmacist with a simple phone call to transfer care.

Z ZZzzzz, Information Technology

So where is Ms Connor's criticism of the GP that made the assumption of delivery without contacting the pharmacy? Honestly!

Richard Judge, Manager

Also, the EPS system does highlight clinical urgency. Urgent items are marked as acute.

Sachin Badiani, Pharmacy owner/ Proprietor

Acute, but can wait till tomorrow or today? Does not go far enough..

Richard Judge, Manager

 It was expected "that day or the day afterwards" 

Richard Judge, Manager

Pharmacy systems will not automatically print a token if one has already been printed at the surgery. I would speculate that the surgery system is set to print prescribing tokens for acute scripts. The EPS script would arrive at the pharmacy but no token. The message would be marked that a token was printed. I would put money on the token being on a printer at the surgery or in a print queue on a computer there not at the pharmacy.

Community Pharmacist, Locum pharmacist


Community Pharmacist, Locum pharmacist

GP expected it to be "actioned urgently" and delivered , "that day or the day afterwards", Ms Connor said

Can’t wait for the futuristic age of telepathy!!


Stephen Eggleston, Community pharmacist

Irrespective of anything else, a simple phone call from the prescriber to the pharmacy would have avoided all this

Caroline Jones, Community pharmacist

Mmmm.....agree with a system to flag urgent, one off prescriptions; but to assume a pharmacy will deliver it is very presumptuous given this is a free, non contracted service! Maybe this Dr should have considered having g systems in place to have it delivered themselves instead of assuming someone else will foot the cost of this?

A Hussain, Senior Management

As mentioned, once a prescription is sent, you are not free of responsibility.  If there is an important message then the surgery need to be confident that it has been received.  A message in tiny font on the repeat slip does not suffice in my opinion.

Charles Whitfield Bott, Pharmacist Director

Sorry is the coroner saying that this patient died because madication was not delivered to them, a service which WE DONT GET PAID TO DO.

Well can organise themsleves however they like and any messages can already be attached to an eps script, the problem is they are very slow. I would expect all scripts that I get via eps to be delived that day or  the next, as long as we can get stock, oh wait!  Maybe the coroner would like to comment on how funding cuts and the refusal to pay us the market price for drug is going to cause deaths.


C A, Community pharmacist

No the coroner said that even if the antibiotic had been delivered it likely wouldn't have affected the outcome for this patient. He was raising concerns about future cases where a delayed script may be attributable to a patient death.

Brian Austen, Senior Management

There is a system that already exists; somebody in the GP Practice telephoning the Pharmacist/Pharmacy and saying it is important that the prescription is dispensed and delivered today. That's what happened when I was a Practice Director and produced a Practice Prescribing Protocol for all practice staff.

Sandra Ball, Production & Technical

Agreed Brian, when a prescription is deemed to be urgent there must be two-way dialogue between the prescriber and the pharmacist. Simply replacing this with a one-way “fire and forget” is fraught with risk. The existing, telephone based, process still exists and should be used.

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