Richard Breatnach
PFD Report
Partially Responded
Ref: 2016-0330
1 of 2 responded · Over 2 years old
Sent To
Response Status
Responses
1 of 2
56-Day Deadline
10 Nov 2016
Over 2 years old — no identified published response
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Coroner's Concerns
_ (1) Mr Breatnach (and anybody else) is able to apply online for medications (2) That applying online, if the application form is not thoroughly checked allows the applicant to lie or give false or misleading answers to critical questions which is what Mr Breatnach did.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach's GP to find out if the answers that he gave were true Prescribing Dihydrocodeine potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice (5) The amount of Dihydrocodeine prescribed appears to be excessive_ (6) understand from the evidence that heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication_ The instructions were that the Dihydrocodeine should be taken four to six hours as required_ The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is heard not the way Dihydrocodeine should be prescribed_ (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency The medication came in three packets one containing one hundred tablets and the other two containing twenty eight tablets each The_two packets containing twenty eight tablets every
VERONICA HAMILTON-DEELEY, LLB.
(3) There was no evidence that the prescriber made any effort to contact Mr Breatnach's GP to find out if the answers that he gave were true Prescribing Dihydrocodeine potentially addictive drug, used for the treatment of moderate to severe pain to a patient who the prescriber has never seen appears to fly in the face of good prescribing practice (5) The amount of Dihydrocodeine prescribed appears to be excessive_ (6) understand from the evidence that heard at the Inquest that Dihydrocodeine should not be prescribed for migraine which is the reason Mr Breatnach gave for asking for this medication_ The instructions were that the Dihydrocodeine should be taken four to six hours as required_ The evidence at the Inquest was that taking Dihydrocodeine in this way, potentially suggesting that eight tablets could or should be taken every twenty four hours until the whole of the one hundred and twenty six tablets given are used up is heard not the way Dihydrocodeine should be prescribed_ (8) Prescribing this number of tablets would therefore seem to be completely inappropriate and fails to understand that medications such as Dihydrocodeine can be used as currency The medication came in three packets one containing one hundred tablets and the other two containing twenty eight tablets each The_two packets containing twenty eight tablets every
VERONICA HAMILTON-DEELEY, LLB.
Responses
Response received
View full response
Dear Ms Hamilton-Deeley, Thank you for your letter of 15"h September 2016 and the report written under Paragraph 7 , Schedule 5 of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroner's (investigations) Regulations 2013, setting out the sad circumstances surrounding the death of Mr Breatnach: note there are nine express concerns set out by the Coroner in the Regulation 28 report which generally concern the prescribing of drugs on-line. It may be helpful if explain that NHS England is formally known as the NHS Commissioning Board in legislation (Section 9 Health & Social Care Act 2012 amending Sections 1G & 1H of the NHS Act 2006). The Board's functions and duties are set out in that legislation too and include duty in respect of commissioning arrangements for NHS services. These include commissioning primary care services (including general practice and pharmacy), managing performer's lists and maintaining the pharmaceutical list_ We also have responsibility for ensuring that primary care contractors work within the terms of their contract; or for pharmacies under their Terms of Service which are outlined in the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations
2013) and can take action such as issuing breach notices and requiring action or withholding payments in certain circumstances As noted in my letter of 27th July 2016, NHS England has, what may be termed, "systems oversight" role for the safe use of controlled drugs (including dihydrocodeine) under the Controlled Drugs (Supervision and Management of Use) Regulations 2013. We raised the issues arising from this case at the Care Quality Commission National Controlled Drugs Group on 14th June 2016 and hosted multiagency meeting to discuss these issues further on Znd November
2016. Representatives from the Police Force, Care Quality Commission Department of Health, General Medical Council General Pharmaceutical Council; Medicines and Healthcare products Regulatory Agency, NHS England, NHS Improvement and the British Medical Association General Practitioners High quality care for all, now and for future generations City = Your
Committee attended (a full list of attendees is set out in Annex and a brief explanation of the role of each of the organisation to assist the Coroner in understanding the nature and extent of various Regulatory bodies involved in this issue_ The group agreed to work together to assimilate current regulatory and professional guidance into one place so there is greater clarity regarding good practice in respect of online prescribing and supply of medicines giving particular guidance on medicines such as controlled drugs and antibiotics. Agencies also shared intelligence on this case_ Regulators agreed to work together further to look at protecting vulnerable patients in future NHS England will use this learning to inform its Digital Strategy: We will also include advice to General Practitioners about Special Patient Notes, which are used within the integrated urgent care software so alerts can be set up for NHS 111 call handlers and out of hours general practitioners when they access particular patient record as part of the Pharmacy Urgent Medicines Supply service being introduced from Ist December 2016. We will continue to discuss the Coroner's concerns and endeavour to develop strategies in partnership with other responsible agencies aimed at preventing future deaths_
2013) and can take action such as issuing breach notices and requiring action or withholding payments in certain circumstances As noted in my letter of 27th July 2016, NHS England has, what may be termed, "systems oversight" role for the safe use of controlled drugs (including dihydrocodeine) under the Controlled Drugs (Supervision and Management of Use) Regulations 2013. We raised the issues arising from this case at the Care Quality Commission National Controlled Drugs Group on 14th June 2016 and hosted multiagency meeting to discuss these issues further on Znd November
2016. Representatives from the Police Force, Care Quality Commission Department of Health, General Medical Council General Pharmaceutical Council; Medicines and Healthcare products Regulatory Agency, NHS England, NHS Improvement and the British Medical Association General Practitioners High quality care for all, now and for future generations City = Your
Committee attended (a full list of attendees is set out in Annex and a brief explanation of the role of each of the organisation to assist the Coroner in understanding the nature and extent of various Regulatory bodies involved in this issue_ The group agreed to work together to assimilate current regulatory and professional guidance into one place so there is greater clarity regarding good practice in respect of online prescribing and supply of medicines giving particular guidance on medicines such as controlled drugs and antibiotics. Agencies also shared intelligence on this case_ Regulators agreed to work together further to look at protecting vulnerable patients in future NHS England will use this learning to inform its Digital Strategy: We will also include advice to General Practitioners about Special Patient Notes, which are used within the integrated urgent care software so alerts can be set up for NHS 111 call handlers and out of hours general practitioners when they access particular patient record as part of the Pharmacy Urgent Medicines Supply service being introduced from Ist December 2016. We will continue to discuss the Coroner's concerns and endeavour to develop strategies in partnership with other responsible agencies aimed at preventing future deaths_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action.
Report Sections
Investigation and Inquest
On 24th August; 2016 commenced an investigation into the death of Philip Richard David BREATNACH otherwise Richard BREATNACH. The investigation concluded at the end of the inquest on 24th August; 2016. The conclusion of the inquest was
Circumstances of the Death
See Record of Inquest
Copies Sent To
General Pharmaceutical Council 6,. Royal Pharmaceutical Society 8_ General Medical Council 9_ Sussex Police GP Brighton
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.