In the first new case, the failure related to the shortcomings of patient record handling within primary care. The patient had moved practices, registering with a new practice on 28 November 2019. The patient’s medical records did not arrive at the new practice until late January, shortly before her death on 2 February 2020.
This delay resulted in a practice pharmacist prescribing oxycodone to the patient without access to the patient’s notes which would have shown that oxycodone was used in a previous suicide attempt.
Whilst individual GPs or pharmacists working in general practice have no influence over the transfer of patient records, the PDA feel it is worth advising members to exercise caution when prescribing for patients in the absence of their previous records, particularly where the request is for high-risk medication such as opiates.
The second case involved the admission of a patient to hospital following an accidental overdose of morphine sulphate liquid. Following discharge, the coroner’s court heard from a witness that this admission and discharge would have resulted in a note being added to the ‘Active Problems’ section of the patient’s record to advise of a recent overdose. However, the discharge did not result in morphine liquid being removed from the patient’s repeat list and when the patient requested a repeat it was issued since the request was within the permitted timescale. In this situation, there would be no further checks and the patient record would not be accessed before the prescription was signed. The patient received a 500ml bottle of morphine liquid on 31 October and was found dead on 5 November having ingested a fatal amount of morphine.
For practice pharmacists it is worth revisiting their practice processes:
- What practice processes are in place when dealing with repeat prescriptions for opiates?
- What processes are in place to review recently discharged patients following admission for an overdose of a prescribed drug and what actions are taken to mitigate the risk of repeated overdose?
Practices might also want to consider introducing policies which require new patients to provide details of their previous practice and consent to contact the practice to confirm the medication requested if their clinical notes have not yet arrived.
You can read the Prevention of Future Deaths reports here:
First case
Second case
