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‘Peculiarity’ of electronic prescription system led to patient death, warns coroner

A ‘peculiarity’ in the NHS Digital electronic prescription service led to a patient dying after they did not receive vital medicine, according to a coroner’s report.

report to prevent future deaths found the patient's prescription failed to reach the nominated pharmacy - despite it being ordered by their GP - because details were later changed on the system to stop all further medications from being sent there.

David Urpeth, assistant coroner western region of South Yorkshire, said in the report that 'unbeknown' to the GP, making these changes meant the prescription was unable to be downloaded by the chemist. 

On 18 April 2019, Sheffield patient Sandra Scott was prescribed trimethoprim for a urine infection by the Royal Hallamshire Hospital in Sheffield, which also conducted a urine test.

The GP, from Upwell Street Surgery, saw the results of the urine test on the same day and prescribed amoxycillin because the results showed Mrs Scott had a urinary tract infection that would not be ‘receptive’ to treatment with trimethoprim.

They issued the prescription electronically to a pharmacy nominated by Mrs Scott and then soon after changed the details on the system so future prescriptions wouldn’t be sent to the nominated chemist.

However, the changes meant the original prescription was never sent to the nominated pharmacy and Mrs Scott did not receive the prescription of amoxycillin.

Additionally, the inquest revealed the hospital received the urine results on 20 April but did not act on them as Mrs Scott had already been discharged.

Mrs Scott was admitted to Royal Hallamshire Hospital on 22 April with ‘worsening’ symptoms and was treated appropriately but died the next day.

The coroner said the GP, their practice colleagues and other healthcare professionals are unaware of the ‘peculiarity’ in the electronic prescription system.

The report said: ‘The GP issued a prescription to a nominated chemist, but a few minutes later put the system details back to what they were before the prescription was issued. Unbeknown to the GP these changes meant the prescription was no longer available for download by the chemist.

‘This resulted in the patient not getting required medication.’

Mr Urpeth added: ‘The evidence was that had the patient received the medication prescribed by the GP or indicated by the hospital results, then she would not have died when she did.

‘There is the potential for wide learning from this tragic case.’

Mr Urpeth has sent his report to the chief executive of NHS Digital, the chief executive of the Royal Hallamshire Hospital, the Sheffield CCG chief executive, and the practice manager of Upwell Street Surgery, which all have until 2 January 2020 to respond.

Another recent coroner’s report criticised a hospital chain’s discharge policy as it left GPs without vital patient information.

Readers' comments (16)

  • So its GPs fault or eps fault not failure of hospital to act on own results??

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  • hospital should act on their own results; by putting themselves out to help the patient the GP has now put themselves in the poo; fantastic; bet they feel like that was well worth it

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  • Where's Optimus?

    Surely the abnormal result needed a call back to the patient to explain and for them to collect the new script
    .. the patient would then chase up with the gp if they could not get the script from the chemist ??
    ... Looks like too many assumptions that the right activity will occur without talking to anyone ...

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  • it is always the responsibility of the person requesting an investigation to ensure that results are acted on.

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  • Socialism

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  • The responsibility lies with whoever orders the test. This is what happens when hospital work dump. How about if GPs dump results for the hospital? No. We are far too nice.

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  • Missed opportunity to comment on the role of antibiotic resistance here?

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  • doctordog.

    Again and again, lack of communication causes serious problems.

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  • In response to AL "4 TRIES IN ONE GAME" BUNDY:
    "They issued the prescription electronically to a pharmacy nominated by Mrs Scott", so she obviously did know about it.
    Not allowed to hold patients responsible for their own health though, are we!

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  • The coroner has missed a chance to comment on unsafe discharge practices of the hospital, antibiotics resistance and patient responsibility.
    What happens if the patient went to a friends house out of Gp area following her admission? It is the hospital who is responsible to ensure their results are appropriately acted on. The patients outcome is on their heads.
    I feel sorry for the gp who went beyond their duty and got sucked into a stressful inquest.

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