Coroner Nigel Parsley last week (January 31) called for a review of “the current...online prescription service” in his report on the death of a patient who obtained drugs from an online pharmacy via a “tick-box exercise”.
The senior coroner for Suffolk said that Kim Robinson “had suffered for many years with chronic and debilitating leg and back pain, for which she took prescribed medication”.
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“[Robinson] also suffered with her mental health and had previously taken overdoses of her prescribed medication,” he added.
He said at the time of her death, Robinson had not been prescribed her anxiety, heart and blood pressure medication by her GP, “but had obtained a supply from an online pharmacy”.
“The process required to do this was described as a ‘tick-box’ exercise in court,” he added.
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Parsely said while carrying this out, Robinson “supplied the required details, rather than her correct details”.
“Had access to Kim’s GP records been available to the prescribing clinician, the prescription... [would] not have been made,” he added.
“Fatal quantity”
Parsely’s report said that Robinson’s “normal prescriptions were secured by a loved one, who controlled the amounts of prescription medication [that she] could access at any one time”.
“When delivered, the package…was addressed to [Robinson], providing her direct access to a fatal quantity of prescription medication,” it added.
It said that she died on May 12, 2024, “at her home address in Suffolk”.
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It added that toxicological analysis found Robinson had the drug “significantly above the toxic level” in her system.
“Had the online prescription not be made, Kim’s death would not have occurred,” Parsley said.
“Would not have issued a prescription”
The report said that during the inquest the GP who had prescribed the drug to Robinson “reviewed the current online system in place and identified five areas where…changes could be made”.
The GP stressed that there was a “need for online prescribers to be able to access a patient’s records – at least the summary care records”.
“These records could be attached to the consultation for review by the prescriber,” he added.
He also suggested that a notice should be sent to a patient’s GP provider “at the same time the medicine is delivered to the patient”, and that without this “the patient’s order should not be accepted”.
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The GP said prescribers “could have the ability to add comments when reviewing a consultation”, including whether it is approved or vetoed, and that all consultations should ask whether a patient has had suicidal thoughts.
“Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine,” he added.
“Had these features been present on the online system, the GP stated he would not have issued a prescription,” the report said.
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Parsely sent his report to the department of health and social care (DH), which today (February 6) told C+D that its “deepest sympathies are with Robinson’s family and friends in this tragic case”.
“It is important that we learn the lessons from every prevention of future deaths report and we will consider the report carefully before responding in due course,” it added.
“The General Pharmaceutical Council (GPhC) have recently updated their guidance for online pharmacies to strengthen their safeguards to prevent people from receiving medicines that are not clinically appropriate for them and may cause them harm,” it said.
Multiple deaths
Parsley sent his report to the Chief Coroner and stressed that “the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court” some six years earlier.
In 2019, Parsely completed an inquest on “the tragic death of Deborah Headspeath”, who died after receiving “significant quantities of codeine from 16 different online suppliers in addition to that prescribed by her GP”.
Read more: Coroner: Patient overdoses after ‘excess’ bank holiday diazepam and codeine scripts
At the time, Parsely said that the inquest “clearly demonstrated that [the] system was totally ineffective”.
Meanwhile in 2023, a coroner raised concerns following a 22-year-old student’s death by suicide after she obtained multiple prescriptions from several online pharmacies.
New online pharmacy regs
This week, the General Pharmaceutical Council (GPhC) introduced new rules banning online pharmacies from prescribing based on online questionnaires alone.
The GPhC guidance sees new expectations for British pharmacists to “independently verify” information provided by patients before prescribing high risk drugs.
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The regulator said that information could be verified “either through timely two-way communication with the person, accessing the person’s clinical records, or contacting the person’s GP, their regular prescriber or a third-party provider”.
But the guidance said that prescribers can choose “not to use two-way communication” if they “make a record, specific to the individual person’s circumstances, justifying their reasons”.
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