Source · Prevention of Future Deaths

Alan Mitchell

Ref: 2025-0577 Date: 10 Nov 2025 Coroner: Alexander Frodsham Area: Cheshire Responses identified: 1 / 1 View PDF

A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.

Date 10 Nov 2025

56-day deadline 5 Jan 2026 est.

Responses identified 1 of 1

Alcohol, drug and medication related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Although the removal by the software of Mr. Mitchell’s repeat prescription played no causative part in his sad death, the alteration to a lifelong prescription without notification (nor any choice being given to) the GP gives rise to the risk that a patient will not be provided with the medication they need. That risk is heightened when patients are elderly and/or prescribed multiple medications and/or when, as here, they do not re-order as they possess medication in reserve.

Responses

1 respondent

Optum Other

18 Dec 2025 PDF

Noted

Optum conducted an internal review of the EMIS Web system and concluded that no software developments beyond the existing functionality are required to mitigate the risk raised in the report, explaining how the system manages repeat prescriptions and their expiration. (AI summary)

View full response

Dear Mr Frodsham,

We write in response to the Regulation 28 Report dated 10th November 2025 (the “Report”).

We were sorry to read about the passing of Mr Mitchell, and we would like to take this opportunity to offer our condolences to his family following their loss.

We have undertaken an internal review of EMIS Web (the “System”), focusing on the issue raised as a concern in the Report. We understand you were informed, during the inquest, that the System automatically removes medication from the list of repeat prescriptions if it is not re-ordered for a period of 12 months. Further, the GP is not notified of this fact and is not prompted to authorise the change. Unfortunately, this information is not quite correct, as detailed below.

This review was undertaken by our internal team, including a Clinical Director, a Clinical Safety Officer and a Product Manager.

Investigation Findings The System has functionality that addresses repeat medications that have not been issued for a period of time, in order to prevent outdated or inappropriate medication from remaining active indefinitely. This helps mitigate the risk of inappropriate medication usage and/or medication wastage arising from patients ordering repeat medications that they no longer require. This is in line with guidance from within the Royal College of General Practitioners and Royal Pharmaceutical Society Repeat Prescribing Toolkit (2024).

How the functionality works Within the System platform, there is a “Medication” tab, under which all medication for a patient is managed by the relevant GP within that patient’s care record. A GP can add a drug, end a course, reauthorise, issue (amongst other functions) medication, as well as manage acute and repeat prescriptions.

Repeat medication does not automatically expire unless a System user (who has the appropriate Role-Based Access Control authority) configures the setting in EMIS Web for such expiry date (please see the Knowledge Based Article (KB0063211)). Without this configuration, the functionality has a default setting so that the repeat prescription remains active and the System will not automatically cancel repeat medication.

When the relevant System user activates this functionality (as per the screenshot below) they can also configure the time period that the System will use, with the minimum time period being 1 year.

To illustrate, where a System user activates the functionality and configures it to 1 year, the System calculates this time using the following logic: 

• Last issue date + the course duration + the value entered in 'Automatically cancel repeats not issued for' in the Organisation’s medication configuration settings. 

Therefore, for a repeat medication with a last issue date of 01/01/25 and a course duration of 28 days; the course duration is added to the last issue date, making 29/01/25 and then the value entered in the 'Automatically cancel repeats not issued for' field is added meaning the repeat medication will expire on 29/01/26 (if no further issues are made during that period).  Once this time period has passed, the System will ‘end’ the medication course and move it from ‘Current’ medication to ‘Past’ medications as that is how a System user has configured the functionality.

The minimum time period for the expiration of repeat medications is set as 1 year from the end of a medication course duration, to enable GP Practices to identify patients that are not requesting repeat medications within this period (i.e. through a patient’s regular / annual medication reviews with their GP), and act accordingly prior to the System cancelling the repeat medication. It should be noted that a GP has access within the “Medication” tab to view “Current” and “Past” medication for any patient at any time.

Conclusion Optum always looks for opportunity to enhance its products to enable clinicians to be best supported when taking ultimate responsibility for any clinical decisions and / or care that is provided.

In this instance, based on the information provided in the Report and our subsequent review, we do not believe there are any software developments beyond the existing functionality in the System that are required to mitigate the specific risk raised in the Report.

We trust that the details outlined above assist. If you have any further queries then please contact me in the first instance.

Kind regards,

Chief Clinical Information Officer

Report sections

Investigation and inquest

On 18 March 2025 I commenced an investigation into the death of Alan MITCHELL aged 88. The investigation concluded at the end of the inquest on 03 November 2025. The conclusion of the inquest was that: Natural causes

Circumstances of the death

Alan Mitchell had a medical history which included Barrett’s Oesophagus. The condition had been diagnosed in 2011 with a recommendation for lifelong management with PPI medication and continued surveillance by way of periodic gastroscopies. In 2020 Mr. Mitchell stopped ordering the PPI medication on repeat prescription from his General Practitioner. At inquest, evidence was heard that, if a prescription is not re-ordered for a period of 12 months, that medication is removed by the EMIS software and no longer appears on the list of repeat prescriptions; further, that the General Practitioner is not notified of this fact and is not prompted to authorise the change. Therefore the GP is required to re-prescribe the medication which the system has removed, and this was done twice in Mr. Mitchell’s case. At a routine medication review in 2021, Mr. Mitchell told his GP that he was not experiencing symptoms which required him to take more than one tablet per month. On 8th March 2025, Mr. Mitchell was admitted to Macclesfield District General Hospital, with evidence of an upper gastro-intestinal bleed. Although a gastroscopy was planned, this was not performed as there was no evidence of active bleeding and Mr. Mitchell’s underlying cardiac condition placed him at risk of a cardiac event during the procedure. On 12th March 2025, Mr. Mitchell complained of chest pain and was short of breath; an ECG revealed that he had suffered a heart attack. Mr. Mitchell became unresponsive and he died at the hospital a short time later.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0577
Date of report: 10 November 2025
Coroner: Alexander Frodsham
Coroner area: Cheshire

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 5 Jan 2026 (estimated).

Sent to

Optum

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.