Dyllon Milburn

Dear Mr Golombeck,

I write in response to your regulation 28 report, dated 21 May 2021, regarding the death of Dyllon Shaun Graham Milburn. I would like to express my sincere condolences to Mr Milburn’s family.

We have reflected on the circumstances surrounding Mr Milburn’s death, and the concerns raised in your report, in relation to NICE’s work. You suggest that an automated alert be added to the EMIS system to remind people to request and collect their repeat prescription to encourage compliance. While NICE is not able to influence changes to the EMIS system, the following NICE guidelines contain recommendations relevant to this report.

In our guideline on medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence (CG76), we recommend considering ‘using records of prescription re˗ordering, pharmacy patient medication records and return of unused medicines to identify potential non˗adherence and patients needing additional support’.

We also recognise the importance of checking adherence in people being treated for depression in our guideline on the recognition and management of depression in adults (CG90).

NICE produces tools to support implementation of our recommendations, but they are put into practice locally. Therefore, we do not consider that any action is required by NICE in response to your report.

I hope the above information is helpful. Thank you for requesting our contribution.

SUBMISSIONS FOR HM CORONER FOLLOWING THE INQUEST HEARING FOR DYLLON MILBURN

At the hearing on 29 April 2021, HM Coroner Zak Golombeck, raised questions over the repeat prescribing system at Bodey Medical Centre (“the practice”). Dr who appeared at the Inquest as a representative of the practice attended a meeting with her partners at the practice following the Inquest when there was a discussion about those matters which HM Coroner asked to be addressed. In providing this information, Dr has obtained the collective views of her three partners at the practice who endorse these comments.

1. The current electronic software system and the details of the provider

The practice software provider is EMIS Health. The version they use is EMIS Web and they use EMIS Web EPS (Electronic prescriptions Service) to prescribe at Bodey Medical Centre. The contact details the practice has for EMIS Health are:

EMIS support at https://www.emishealth.com/about-us/contact-us/

Head Office Leeds - Fulford Grange Fulford Grange Micklefield Lane, Rawdon Leeds LS19 6BA

or Regional offices Bolton - Aspinall House Aspinall House Aspinall Close Middlebrook, Horwich, Bolton BL6 6QQ

There are three methods by which patients of the practice can request their repeat prescriptions. Firstly, they can set up a system with their local pharmacy whereby the pharmacy requests the patient’s medication on a monthly basis on their behalf. Secondly, the patient can set up online registration and request their medications online through the practice website. Thirdly, the patient can fill in their paper repeat prescription slip and give this in manually either by giving it to one of the receptionists or by posting it in the repeat prescription slip box in the waiting room.

For each of these options, a prescription request takes at most 2 working days for the practice to review, sign and process the prescription. This has to be done by a doctor or qualified nurse prescriber. The practice therefore asks their patients to request their repeat prescriptions at least 2 days in advance. The requirement for a 2-day processing time is prominently displayed on the repeat prescribing section of the website and on the repeat prescription slip boxes in the reception area at the practice.

In this case the patient was set up for electronic prescriptions (option 2) that were sent automatically to a pharmacy. If a patient wishes to change their nominated pharmacy, they can do so by either arranging this in their new preferred pharmacy, or if they inform the practice of a new preferred pharmacy, the practice can change the details on their system in EMIS.

When an antidepressant is added to a repeat prescription, this is done in discussion with the patient and with their consent. The discussion includes how to take the medication, the expected duration of the course and the need to wean off the medication. The patient is "safety netted" i.e. they are advised to seek a consultation with a GP if there is a problem with their medication at any time or if they experience a deterioration in their mental health.

When electronically signing a repeat prescription, the number of prescription requests are mapped on the system to the patient's daily quantity so there is a percentage estimate visible to the signing clinician which might indicate if the patient was not requesting their medication as they should be. When adding a new repeat medication on EMIS the prescribing clinician must authorise how many times this repeat prescription can be issued. This authorisation number indicates the maximum number of times the prescriber can issue that medication from the patient’s repeats before they need a review of that medication. The maximum time before each review would be for one year (i.e.12 issues of a 28 day quantity of medication might be authorised when initiating a repeat prescription for a medication if it was appropriate for this medication to be continued for 1 year).

On an annual basis every patient has a medications review. This also applies to anti- depressants on repeat prescriptions. At the annual medication review, the reviewing GP would routinely check that any repeats were being regularly collected. If they were not, appropriate action is taken which could involve removing the medication from repeats, and either swapping the medication from “repeats” to “acutes” or it could trigger a patient to be requested to come in for a review with a GP.

2. Comments on how an alert in the system would work in practice

In discussion at the practice meeting, the clinicians commented that there is no electronic system that they are aware of which can alert them as to whether a patient is not requesting their repeat medications on a month-by-month basis. If such a system existed and were workable, there would need to be a protocol in place to clarify how the patient would be alerted to this. Possibilities discussed included by text message if the patient consents to this, by telephone (if so, the question arises as to who makes the call), or by letter for patients without access to phones (again raising the question as to who writes the letter). There would also need to be clarity as to what timeframe applied i.e. when such an alert would be triggered. What would be the appropriate timescale for alerting as to a late request for a prescription? Would this be days or weeks and if so, how many?. There would also need to be a protocol in place to detail what an appropriate response would be when such an alert was triggered. Given that an alert would have to apply to all medications to all patients across the practice, there are concerns about the volume of alerts that may be triggered and that the practice does not have sufficient resources to provide an appropriate response to such alerts either in terms of administrative or clinician staffing or time.

Finally it would seem that the possibility of alerts in a prescribing system would have far reaching consequences for GP practices nationally and that careful consideration would need to be given to the various medications issued on repeat prescription which are wide ranging. It may be that consultation with NICE is appropriate and any other relevant prescribing bodies in the UK.

, Legal Adviser, Medical Protection Society on behalf of Dr , Bodey Medical Centre

12 May 2021