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.