1. During the Inquest evidence was heard that:-

i. The deceased was receiving a daily prescription of methadone to be collected and administered on a daily basis from the Pharmacy. The prescriptions were not collected from the Pharmacy on Monday the 18th June 2017, Tuesday the 19th June 2017 and Wednesday the 20th June 2017.

ii. There is a system, referred to at the Inquest as a “red flag system”, for a pharmacy to report the non-collection of a prescription of methadone when a patient has not collected the medication on three consecutive occasions. The evidence at the Inquest indicated that the purpose of the report by a pharmacy of non-collection is to enable the Key Worker to be made aware of the non-collection of the medication so that the Key Worker could take appropriate action to contact the patient and to check whether any concerns need to be addressed.

iii. The Key Worker attached to the deceased was , who is a Key Worker employed by Addaction, and she gave evidence that the procedure relating to the deceased, and other patients, to report non-collection of medication is for the report to be sent by a pharmacy to GMMH and not directly to the Key Worker. In the case of the deceased, , the deceased’s Key Worker, did not receive a report that the deceased had not collected his methadone on the above dates and she only became aware of his non-collection of methadone by her own enquiry when she telephoned the Pharmacy to request that the prescription of methadone be placed on hold.

iv. also gave evidence that some patients, particularly those patients who are known to be diligent and to collect their medication on time each and every day, may require a report of non-collection of medication earlier than three days because, in relation to those patients, a single failure to collect medication may raise concerns and require enquiries by the Key Worker as to any concerns, in view of the fact that those patients always collect their medication each and every day.
v. GMMH is a Mental Health NHS Foundation Trust and is separate in terms of governance, even though working in partnership to an extent, from Addaction, which is described as a Drug, Alcohol and Mental Health Treatment Charity. Accordingly, any report relating to the non-collection of medication addressed to GMMH requires a further onward report from GMMH to Addaction. The governance of GMMH has no control over Practitioners employed by Addaction and GMMH and Addaction do not share computer reporting systems.

2. I request a review of the system referred to at the Inquest as the “red flag system” in relation to the reporting of patients who fail to collect prescribed medications, particularly where the patient is due to collect prescribed medications on a daily basis.

The review should consider:-

i. The reporting of a failure to collect prescribed medication direct to a designated and named Key Worker, who may not be within the employment of GMMH, to avoid the report being processed by an intermediary, who does not employ or control the Key Worker.

The review should consider the most expeditious route to report the failure to collect prescribed medications to a Key Worker, who has the responsibility in relation to the patient and who will have direct contact with the patient. The Key Worker will be the most expedient method of contact with the patient.

ii. The timescale in relation to a report being submitted to the Key Worker, taking account of the fact that the present three day timescale may not be appropriate for patients who are known to be very compliant and who collect prescriptions on a regular daily basis. In those circumstances the concern and the need to check the concern may arise after either one or two failures to collect the prescribed medication.

iii. The training of pharmacy, mental health practitioners and any other healthcare professionals in relation to the reporting of failures to collect prescribed medication taking account of the circumstances relating to the case of the deceased, where the failure to collect the prescribed medication was not reported, as soon as practicable, after the third consecutive failure to collect the medication.