Amicus Health
Action Taken
Amicus Health will flag high-risk patients prescribed medications for closer monitoring with regular reviews and shorter prescriptions. They have eliminated non-auditable messaging systems for clinical information to ensure transparency and accountability in prescription management. (AI summary)
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Dear HM Assistant Coroner Nicholson, Thank you for your Regulation 28 Report regarding the tragic death of Mr. Oliver James Billings. First and foremost, we extend our condolences to Mr. Billings’ family. We are deeply sorry for their loss and are committed to taking meaningful actions to prevent similar tragedies in the future. We have carefully reviewed the concerns raised in your report, as well as the findings from and actions taken following our internal investigation. We have taken steps to ensure that the lessons learned are fully integrated into our processes and practices to safeguard against similar occurrences. Response to Concerns:
1. Issuance of Subsequent Prescription Without Confirmation of Cancellation We recognise the critical need for ensuring that a previously issued prescription has been fully cancelled before generating a new one. Our internal review identified that initially the action taken was correct in that when Prescription Clerk A was asked by Mr Billings to change where the prescription was being sent, she informed him that he would need to contact Pharmacy2u to ask them to release the prescription so that his preferred pharmacy could dispense the prescription instead. This is in line with our policy and ensures that there is not a duplication of prescription. The process to change a pharmacy once the prescription has been sent involves contacting pharmacies directly and at present there is not a direct route for practices to easily do this. Where this change is at patient request, rather than as result of an error, we put the onus back on the patient to arrange this. In usual circumstances a duplicate prescription should not be issued whilst there is still a live prescription in process. We can see that in the case of Mr Billings, after he had been told to contact pharmacy2u by Prescription Clerk A, Prescription Clerk B cancelled the first prescription through our clinical system. This did not cancel the prescription for pharmacy2u as the prescription had already been downloaded. Prescription
Amic u s H e alt h Clare House Amic u s H e alt h Bampton Clerk B then requested a duplicate prescription from a GP. It is not clear from the clinical system what prompted the 2nd clerk to make this request as this was not recorded in the notes. More generally we might see a follow up request if the patient has had difficulty contacting the nominated pharmacy and is worried about running out of medication. Our internal review identified that the cancellation request for the initial prescription did not take effect due to the immediate download of the prescription by Pharmacy2U, which occurred within a minute of issuance. This significantly limits the ability to cancel prescriptions promptly. Whilst we accept that a timely download is important the speed that we see this occur from online pharmacy leaves no room for error/change of request. Please see below timeline of prescription process. Time Date Initial request processed by prescription clerk 12:46 27/11/2023 Prescription 1 signed by GP for 112 x 75mg venlafaxine tablets 14:20 27/11/2023 Downloaded by P2U 14:21 27/11/2023 Prescription Clerk A messaged patient to contact pharmacy to redirect script 16:52 27/11/2023 Re-requested by Prescription Clerk B 17:22 27/11/2023 Prescription 1 cancelled by Prescription Clerk B 17:22 27/11/2023 Prescription 2 signed by GP for 112 x 75mg venlafaxine tablets 17:47 27/11/2023 Downloaded by Superdrug 17:49 27/11/2023 Dispensed by P2U 11:21 28/11/2023 Dispensed by Superdrug 12:04 28/11/2023 Claimed by Superdrug 17:25 28/11/2023 Claimed by P2U 23:25 29/11/2023 Once the prescription has been downloaded by the pharmacy it is difficult to cancel, particularly with online pharmacies who prefer email communication and can have long telephone waiting times. We feel that a review of this system to allow practices to have the ability to cancel prescriptions in a more streamlined way would prevent the need for the additional measures that the practice has put in place to safeguard against duplication of prescriptions. That said, we are committed to taking the steps we can, to prevent any future tragedies and we believe we have taken all measures that are within our control. We have taken the following action to safeguard against any future duplication of prescriptions: Checked with the prescription and GP team to ensure that the cancellation of prescription is always as a last resort. Ensured that the prescription team, if cancelling prescriptions are conducting a dynamic risk assessment to ascertain why this cancellation is required. As a further development a template is being produced to support their thinking on this. Sought assurance that patients, when requesting a change of pharmacy after prescription issue, are given a prescription code and asked to contact the original nominated pharmacy to release back to the spine. Informing them they can then take that code to any pharmacy to prescribe. We do this as
Amic u s H e alt h Clare House Amic u s H e alt h Bampton a first line and have checked with the Devon ICB who are in support of this approach, likening it to giving the patient responsibility by issuing them with a paper prescription. The issue with this often arises when we add in the human factors of frustration, distress, and anxiety when the patient is unable to contact the pharmacy themselves. This can be where the prescription team are prompted to seek an alternative solution and request to cancel the prescription to reissue another. Provided an alternative to cancellation and reissue in cases where the patient is worried about a delay from the pharmacy. Namely asking clinicians to provide a ‘bridging prescription’ to cover the days missing. This reduces the amount of medication being requested and therefore the risk. It also avoids cancelling a prescription. It should be noted that this does however have an additional cost to the patient and the NHS that would be avoided if we could easily cancel and reissue. Should a prescription cancellation request be rejected electronically by the online pharmacy, then the patient is advised to await delivery of said prescription as per their existing agreement with the online pharmacy. Pharmacy2u recommends that the patient requests their new prescription 10 days prior to running out of their existing supply. Bridging prescriptions should not be necessary. However, a bridging prescription of up to 5 days will be offered, where deemed suitable by the authorising clinician following dynamic risk assessment. Asked all prescriptions staff to email Pharmacy2U to communicate cancellations. This is under their direction as their phonelines are not well manned and/or in high demand – They state in their message that they prefer email. A call can take more than an hour to be answered, and it is not sustainable for us to use our limited resource calling them, given their poor answering capacity. Reviewed processes related to rejected prescription cancellation notifications within our clinical system. This is an alert that will tell us within our clinical system if there has been a cancellation request that has been rejected due to already being downloaded by the pharmacy. To ensure that these are monitored, and acted upon when required, a member of the prescriptions team is assigned to review this each day. Ensured all prescription staff are aware that they need to make certain all contact is documented in the notes. As you can see, whilst we have systems in place to overcome the inability to easily cancel a prescription this is not straightforward and does have resource and cost implications for us and the wider system.
2. Swift Dispatch of Medication Preventing Error Correction As noted above we understand that rapid dispatch of medications can limit the window for rectifying errors. Unfortunately, it is not within our scope to change this. We would encourage Pharmacy2U and other online pharmacies to explore the feasibility of implementing a more accessible cancellation process. We feel that the automatic drawdown of prescriptions, which subsequently prevents cancellation should be reviewed to reduce the additional administrative burden on general practice and reduce cost to the NHS in fees, because of unnecessary medication dispensing. As mentioned above, following this incident, our prescription team has implemented a monitoring system to track and manage rejected cancellation requests more effectively.
3. Onus on Patients to Remedy Errors
Amic u s H e alt h Clare House Amic u s H e alt h Bampton As explained above we do ask the patient to contact the nominated pharmacy to ask for the release of a prescription where the nominated pharmacy is being changed at the patient request. Mr Billings was asked to contact pharmacy 2u and ask for the prescription to be returned to the spine following the initial request from him to prescription clerk A that his prescription be sent to a different pharmacy. There was no further action taken at that interaction and no request at that point for a duplicate prescription. No error had occurred. It was the subsequent action from Prescription Clerk B that prompted the duplication of prescriptions and whilst the correct action was not taken at this point to ensure the prescription was cancelled there is no record that Mr Billings was asked to follow this up with Pharmacy2u. Additional Measures Identified During Review: Risk Assessments for High-Risk Medications: Patients identified as high risk of suicide and prescribed medications such as will be flagged for closer monitoring. This includes regular reviews, risk assessments, and ensuring prescriptions are limited to shorter durations to minimise potential misuse. Improved Communication Protocols: We have eliminated the use of non-auditable messaging systems (e.g., screen messages) for clinical information to ensure transparency and accountability in prescription management as we believe that this method was used for communication between Prescription Clerk B and the GP who issued the second prescription. We note that the immediate download of prescriptions by Pharmacy2U poses a significant challenge for error rectification. We would like to see this issue reviewed by Pharmacy2U, other online pharmacy and relevant regulatory bodies and changes implemented enhance patient safety. Specifically, we request easier, more effective means of communication and cancellation. Other industries have online electronic cancellation systems in place. It should be possible for the Pharmacy Industry to do this. We recognised this will come at a cost to them but potentially a huge saving to the NHS in terms of risk and cost. We deeply regret the circumstances surrounding Mr. Billings’ death and are committed to ensuring his legacy drives meaningful improvements in patient care. We trust that these measures demonstrate our commitment to addressing the concerns raised and our determination to prevent similar tragedies in the future. Should you require further details or wish to discuss our response, please do not hesitate to contact us. We also extend this invitation to the family of Mr Billings.
1. Issuance of Subsequent Prescription Without Confirmation of Cancellation We recognise the critical need for ensuring that a previously issued prescription has been fully cancelled before generating a new one. Our internal review identified that initially the action taken was correct in that when Prescription Clerk A was asked by Mr Billings to change where the prescription was being sent, she informed him that he would need to contact Pharmacy2u to ask them to release the prescription so that his preferred pharmacy could dispense the prescription instead. This is in line with our policy and ensures that there is not a duplication of prescription. The process to change a pharmacy once the prescription has been sent involves contacting pharmacies directly and at present there is not a direct route for practices to easily do this. Where this change is at patient request, rather than as result of an error, we put the onus back on the patient to arrange this. In usual circumstances a duplicate prescription should not be issued whilst there is still a live prescription in process. We can see that in the case of Mr Billings, after he had been told to contact pharmacy2u by Prescription Clerk A, Prescription Clerk B cancelled the first prescription through our clinical system. This did not cancel the prescription for pharmacy2u as the prescription had already been downloaded. Prescription
Amic u s H e alt h Clare House Amic u s H e alt h Bampton Clerk B then requested a duplicate prescription from a GP. It is not clear from the clinical system what prompted the 2nd clerk to make this request as this was not recorded in the notes. More generally we might see a follow up request if the patient has had difficulty contacting the nominated pharmacy and is worried about running out of medication. Our internal review identified that the cancellation request for the initial prescription did not take effect due to the immediate download of the prescription by Pharmacy2U, which occurred within a minute of issuance. This significantly limits the ability to cancel prescriptions promptly. Whilst we accept that a timely download is important the speed that we see this occur from online pharmacy leaves no room for error/change of request. Please see below timeline of prescription process. Time Date Initial request processed by prescription clerk 12:46 27/11/2023 Prescription 1 signed by GP for 112 x 75mg venlafaxine tablets 14:20 27/11/2023 Downloaded by P2U 14:21 27/11/2023 Prescription Clerk A messaged patient to contact pharmacy to redirect script 16:52 27/11/2023 Re-requested by Prescription Clerk B 17:22 27/11/2023 Prescription 1 cancelled by Prescription Clerk B 17:22 27/11/2023 Prescription 2 signed by GP for 112 x 75mg venlafaxine tablets 17:47 27/11/2023 Downloaded by Superdrug 17:49 27/11/2023 Dispensed by P2U 11:21 28/11/2023 Dispensed by Superdrug 12:04 28/11/2023 Claimed by Superdrug 17:25 28/11/2023 Claimed by P2U 23:25 29/11/2023 Once the prescription has been downloaded by the pharmacy it is difficult to cancel, particularly with online pharmacies who prefer email communication and can have long telephone waiting times. We feel that a review of this system to allow practices to have the ability to cancel prescriptions in a more streamlined way would prevent the need for the additional measures that the practice has put in place to safeguard against duplication of prescriptions. That said, we are committed to taking the steps we can, to prevent any future tragedies and we believe we have taken all measures that are within our control. We have taken the following action to safeguard against any future duplication of prescriptions: Checked with the prescription and GP team to ensure that the cancellation of prescription is always as a last resort. Ensured that the prescription team, if cancelling prescriptions are conducting a dynamic risk assessment to ascertain why this cancellation is required. As a further development a template is being produced to support their thinking on this. Sought assurance that patients, when requesting a change of pharmacy after prescription issue, are given a prescription code and asked to contact the original nominated pharmacy to release back to the spine. Informing them they can then take that code to any pharmacy to prescribe. We do this as
Amic u s H e alt h Clare House Amic u s H e alt h Bampton a first line and have checked with the Devon ICB who are in support of this approach, likening it to giving the patient responsibility by issuing them with a paper prescription. The issue with this often arises when we add in the human factors of frustration, distress, and anxiety when the patient is unable to contact the pharmacy themselves. This can be where the prescription team are prompted to seek an alternative solution and request to cancel the prescription to reissue another. Provided an alternative to cancellation and reissue in cases where the patient is worried about a delay from the pharmacy. Namely asking clinicians to provide a ‘bridging prescription’ to cover the days missing. This reduces the amount of medication being requested and therefore the risk. It also avoids cancelling a prescription. It should be noted that this does however have an additional cost to the patient and the NHS that would be avoided if we could easily cancel and reissue. Should a prescription cancellation request be rejected electronically by the online pharmacy, then the patient is advised to await delivery of said prescription as per their existing agreement with the online pharmacy. Pharmacy2u recommends that the patient requests their new prescription 10 days prior to running out of their existing supply. Bridging prescriptions should not be necessary. However, a bridging prescription of up to 5 days will be offered, where deemed suitable by the authorising clinician following dynamic risk assessment. Asked all prescriptions staff to email Pharmacy2U to communicate cancellations. This is under their direction as their phonelines are not well manned and/or in high demand – They state in their message that they prefer email. A call can take more than an hour to be answered, and it is not sustainable for us to use our limited resource calling them, given their poor answering capacity. Reviewed processes related to rejected prescription cancellation notifications within our clinical system. This is an alert that will tell us within our clinical system if there has been a cancellation request that has been rejected due to already being downloaded by the pharmacy. To ensure that these are monitored, and acted upon when required, a member of the prescriptions team is assigned to review this each day. Ensured all prescription staff are aware that they need to make certain all contact is documented in the notes. As you can see, whilst we have systems in place to overcome the inability to easily cancel a prescription this is not straightforward and does have resource and cost implications for us and the wider system.
2. Swift Dispatch of Medication Preventing Error Correction As noted above we understand that rapid dispatch of medications can limit the window for rectifying errors. Unfortunately, it is not within our scope to change this. We would encourage Pharmacy2U and other online pharmacies to explore the feasibility of implementing a more accessible cancellation process. We feel that the automatic drawdown of prescriptions, which subsequently prevents cancellation should be reviewed to reduce the additional administrative burden on general practice and reduce cost to the NHS in fees, because of unnecessary medication dispensing. As mentioned above, following this incident, our prescription team has implemented a monitoring system to track and manage rejected cancellation requests more effectively.
3. Onus on Patients to Remedy Errors
Amic u s H e alt h Clare House Amic u s H e alt h Bampton As explained above we do ask the patient to contact the nominated pharmacy to ask for the release of a prescription where the nominated pharmacy is being changed at the patient request. Mr Billings was asked to contact pharmacy 2u and ask for the prescription to be returned to the spine following the initial request from him to prescription clerk A that his prescription be sent to a different pharmacy. There was no further action taken at that interaction and no request at that point for a duplicate prescription. No error had occurred. It was the subsequent action from Prescription Clerk B that prompted the duplication of prescriptions and whilst the correct action was not taken at this point to ensure the prescription was cancelled there is no record that Mr Billings was asked to follow this up with Pharmacy2u. Additional Measures Identified During Review: Risk Assessments for High-Risk Medications: Patients identified as high risk of suicide and prescribed medications such as will be flagged for closer monitoring. This includes regular reviews, risk assessments, and ensuring prescriptions are limited to shorter durations to minimise potential misuse. Improved Communication Protocols: We have eliminated the use of non-auditable messaging systems (e.g., screen messages) for clinical information to ensure transparency and accountability in prescription management as we believe that this method was used for communication between Prescription Clerk B and the GP who issued the second prescription. We note that the immediate download of prescriptions by Pharmacy2U poses a significant challenge for error rectification. We would like to see this issue reviewed by Pharmacy2U, other online pharmacy and relevant regulatory bodies and changes implemented enhance patient safety. Specifically, we request easier, more effective means of communication and cancellation. Other industries have online electronic cancellation systems in place. It should be possible for the Pharmacy Industry to do this. We recognised this will come at a cost to them but potentially a huge saving to the NHS in terms of risk and cost. We deeply regret the circumstances surrounding Mr. Billings’ death and are committed to ensuring his legacy drives meaningful improvements in patient care. We trust that these measures demonstrate our commitment to addressing the concerns raised and our determination to prevent similar tragedies in the future. Should you require further details or wish to discuss our response, please do not hesitate to contact us. We also extend this invitation to the family of Mr Billings.