During a home visit, an elderly, frail patient has no one to collect an urgent prescription and the pharmacy does not provide same-day delivery. What should you do?
Dr Helen Cotton: Review the potential risk
The scenario of patients not obtaining urgent medication has been highlighted recently by the coroner’s report on the death of Douglas Hodges.1
In that case, the prescription was sent electronically and marked for urgent delivery, but system failures resulted in the patient not receiving the prescription. While the cases are not directly comparable, there is a common theme: how can primary care ensure treatment is delivered in a timely manner?
Step one is to review the clinical situation. When will the patient be able to obtain the medication and is that within a safe period?
If you conclude that the medication is definitely needed on the day and the patient cannot arrange to get it themselves, action is needed.
There is no single answer to this and services vary across the country. In an urban area an alternative pharmacy may be able to deliver; some practices might have a support service, or a charity may step in and provide short-term support.
Step two is to establish whether, within the pharmacy opening hours left, there is a way to get the prescription delivered.
This is likely to be a time-consuming process that can be delegated to clerical staff.
If the situation becomes urgent and there is no means of delivering medication, admission is warranted. In some areas step-up and step-down services exist, so the solution might be a community hospital or social care bed, rather than an acute hospital bed.
Should the patient refuse admission, a thorough and well-documented capacity assessment is needed.
At this stage, it would be sensible to discuss the case with colleagues and defence organisations.
Dr Helen Cotton is a GP in Yeovil, Somerset
Dr Pipin Singh: Arrange hospital admission as a last resort
The clinician must consider several factors in order to make a best-interests decision, including: how urgent the prescription really is; the patient’s social circumstances; the patient’s capacity and ability to administer the medication; the likelihood that the condition will rapidly deteriorate over the course of the day; and whether any deterioration could lead to an increased risk of significant morbidity or mortality.
Also important is where the patient wishes to be managed.
Ensure the patient is aware of the urgency of the prescription and the risks of not receiving the medication that day.
It’s important to consider all the possible options available. If the patient is so unwell, it is extremely unlikely to be safe for them to collect the prescription themselves and if they live alone this will affect the management.
A hospital admission needs to be considered, but the following options may also be open to you:
• Could another relative or carer collect it and, if so, can the patient – or you – contact them the same day? If the patient is in a care home, a staff member or family member is likely to be able to collect the script.
• Is there an alternative pharmacist that does same-day deliveries?
• Does the patient have community nurse involvement? If so, are they able to deliver the medication?
• Are there any community beds available?
• Can you deliver the prescription yourself?
If delivery of the prescription still cannot be guaranteed after exploring all these avenues, and the condition might cause harm, a hospital admission will need to be arranged.
Dr Pipin Singh is a GP in Wallsend, Tyne and Wear
Medicolegal view: Dig deeper to explore the circumstances
What you do in this situation will depend on how clinically urgent the prescription is and also what options are in place locally to resolve the problem. While you may wish to do all you can to help personally, the pressures of day-to-day practice are such that it is unlikely that you will be able to collect the prescription and deliver it yourself.
If the prescription genuinely cannot wait until the following day, you should do your best to make sure the patient receives good care and treatment.2
Although the patient has said no one is available to collect the prescription, it is worth asking them if a neighbour or friend can help out and collect it for them.
Alternatively you could ask the patient for permission to approach someone on their behalf.
You may also wish to speak to someone at the community pharmacy. While it may not be the pharmacy’s usual practice to offer same-day deliveries, they may be willing to make an exception.
If the patient’s isolation appears to be a longstanding problem, you might wish to look into what other assistance may be available.3 Consider discussing the situation with the relevant social services team, if the patient gives you permission to do so.
Dr Edward Farnan is a medicolegal adviser for the Medical Defence Union
1 Coroner’s regulation 28 report: Douglas Hodges tinyurl.com/yayl8cmd
2 GMC: Good Medical Practice 2013; paragraph 2 tinyurl.com/ycmkao6p
3 GMC Good Medical Practice 2013; paragraph 27 tinyurl.com/yav23xjm