Dear HM Assistant Coroner Nicholson, Thank you for your Regulation 28 Report regarding the tragic death of Mr. Oliver James Billings. First and foremost, we extend our condolences to Mr. Billings’ family. We are deeply sorry for their loss and are committed to taking meaningful actions to prevent similar tragedies in the future. We have carefully reviewed the concerns raised in your report, as well as the findings from and actions taken following our internal investigation. We have taken steps to ensure that the lessons learned are fully integrated into our processes and practices to safeguard against similar occurrences. Response to Concerns:
1. Issuance of Subsequent Prescription Without Confirmation of Cancellation We recognise the critical need for ensuring that a previously issued prescription has been fully cancelled before generating a new one. Our internal review identified that initially the action taken was correct in that when Prescription Clerk A was asked by Mr Billings to change where the prescription was being sent, she informed him that he would need to contact Pharmacy2u to ask them to release the prescription so that his preferred pharmacy could dispense the prescription instead. This is in line with our policy and ensures that there is not a duplication of prescription. The process to change a pharmacy once the prescription has been sent involves contacting pharmacies directly and at present there is not a direct route for practices to easily do this. Where this change is at patient request, rather than as result of an error, we put the onus back on the patient to arrange this. In usual circumstances a duplicate prescription should not be issued whilst there is still a live prescription in process. We can see that in the case of Mr Billings, after he had been told to contact pharmacy2u by Prescription Clerk A, Prescription Clerk B cancelled the first prescription through our clinical system. This did not cancel the prescription for pharmacy2u as the prescription had already been downloaded. Prescription

Amic u s H e alt h Clare House Amic u s H e alt h Bampton Clerk B then requested a duplicate prescription from a GP. It is not clear from the clinical system what prompted the 2nd clerk to make this request as this was not recorded in the notes. More generally we might see a follow up request if the patient has had difficulty contacting the nominated pharmacy and is worried about running out of medication. Our internal review identified that the cancellation request for the initial prescription did not take effect due to the immediate download of the prescription by Pharmacy2U, which occurred within a minute of issuance. This significantly limits the ability to cancel prescriptions promptly. Whilst we accept that a timely download is important the speed that we see this occur from online pharmacy leaves no room for error/change of request. Please see below timeline of prescription process. Time Date Initial request processed by prescription clerk 12:46 27/11/2023 Prescription 1 signed by GP for 112 x 75mg venlafaxine tablets 14:20 27/11/2023 Downloaded by P2U 14:21 27/11/2023 Prescription Clerk A messaged patient to contact pharmacy to redirect script 16:52 27/11/2023 Re-requested by Prescription Clerk B 17:22 27/11/2023 Prescription 1 cancelled by Prescription Clerk B 17:22 27/11/2023 Prescription 2 signed by GP for 112 x 75mg venlafaxine tablets 17:47 27/11/2023 Downloaded by Superdrug 17:49 27/11/2023 Dispensed by P2U 11:21 28/11/2023 Dispensed by Superdrug 12:04 28/11/2023 Claimed by Superdrug 17:25 28/11/2023 Claimed by P2U 23:25 29/11/2023 Once the prescription has been downloaded by the pharmacy it is difficult to cancel, particularly with online pharmacies who prefer email communication and can have long telephone waiting times. We feel that a review of this system to allow practices to have the ability to cancel prescriptions in a more streamlined way would prevent the need for the additional measures that the practice has put in place to safeguard against duplication of prescriptions. That said, we are committed to taking the steps we can, to prevent any future tragedies and we believe we have taken all measures that are within our control. We have taken the following action to safeguard against any future duplication of prescriptions:  Checked with the prescription and GP team to ensure that the cancellation of prescription is always as a last resort.  Ensured that the prescription team, if cancelling prescriptions are conducting a dynamic risk assessment to ascertain why this cancellation is required. As a further development a template is being produced to support their thinking on this.  Sought assurance that patients, when requesting a change of pharmacy after prescription issue, are given a prescription code and asked to contact the original nominated pharmacy to release back to the spine. Informing them they can then take that code to any pharmacy to prescribe. We do this as

Amic u s H e alt h Clare House Amic u s H e alt h Bampton a first line and have checked with the Devon ICB who are in support of this approach, likening it to giving the patient responsibility by issuing them with a paper prescription. The issue with this often arises when we add in the human factors of frustration, distress, and anxiety when the patient is unable to contact the pharmacy themselves. This can be where the prescription team are prompted to seek an alternative solution and request to cancel the prescription to reissue another.  Provided an alternative to cancellation and reissue in cases where the patient is worried about a delay from the pharmacy. Namely asking clinicians to provide a ‘bridging prescription’ to cover the days missing. This reduces the amount of medication being requested and therefore the risk. It also avoids cancelling a prescription. It should be noted that this does however have an additional cost to the patient and the NHS that would be avoided if we could easily cancel and reissue. Should a prescription cancellation request be rejected electronically by the online pharmacy, then the patient is advised to await delivery of said prescription as per their existing agreement with the online pharmacy. Pharmacy2u recommends that the patient requests their new prescription 10 days prior to running out of their existing supply. Bridging prescriptions should not be necessary. However, a bridging prescription of up to 5 days will be offered, where deemed suitable by the authorising clinician following dynamic risk assessment.  Asked all prescriptions staff to email Pharmacy2U to communicate cancellations. This is under their direction as their phonelines are not well manned and/or in high demand – They state in their message that they prefer email. A call can take more than an hour to be answered, and it is not sustainable for us to use our limited resource calling them, given their poor answering capacity.  Reviewed processes related to rejected prescription cancellation notifications within our clinical system. This is an alert that will tell us within our clinical system if there has been a cancellation request that has been rejected due to already being downloaded by the pharmacy. To ensure that these are monitored, and acted upon when required, a member of the prescriptions team is assigned to review this each day.  Ensured all prescription staff are aware that they need to make certain all contact is documented in the notes. As you can see, whilst we have systems in place to overcome the inability to easily cancel a prescription this is not straightforward and does have resource and cost implications for us and the wider system.
2. Swift Dispatch of Medication Preventing Error Correction As noted above we understand that rapid dispatch of medications can limit the window for rectifying errors. Unfortunately, it is not within our scope to change this. We would encourage Pharmacy2U and other online pharmacies to explore the feasibility of implementing a more accessible cancellation process. We feel that the automatic drawdown of prescriptions, which subsequently prevents cancellation should be reviewed to reduce the additional administrative burden on general practice and reduce cost to the NHS in fees, because of unnecessary medication dispensing. As mentioned above, following this incident, our prescription team has implemented a monitoring system to track and manage rejected cancellation requests more effectively.
3. Onus on Patients to Remedy Errors

Amic u s H e alt h Clare House Amic u s H e alt h Bampton As explained above we do ask the patient to contact the nominated pharmacy to ask for the release of a prescription where the nominated pharmacy is being changed at the patient request. Mr Billings was asked to contact pharmacy 2u and ask for the prescription to be returned to the spine following the initial request from him to prescription clerk A that his prescription be sent to a different pharmacy. There was no further action taken at that interaction and no request at that point for a duplicate prescription. No error had occurred. It was the subsequent action from Prescription Clerk B that prompted the duplication of prescriptions and whilst the correct action was not taken at this point to ensure the prescription was cancelled there is no record that Mr Billings was asked to follow this up with Pharmacy2u. Additional Measures Identified During Review: Risk Assessments for High-Risk Medications: Patients identified as high risk of suicide and prescribed medications such as will be flagged for closer monitoring. This includes regular reviews, risk assessments, and ensuring prescriptions are limited to shorter durations to minimise potential misuse. Improved Communication Protocols: We have eliminated the use of non-auditable messaging systems (e.g., screen messages) for clinical information to ensure transparency and accountability in prescription management as we believe that this method was used for communication between Prescription Clerk B and the GP who issued the second prescription. We note that the immediate download of prescriptions by Pharmacy2U poses a significant challenge for error rectification. We would like to see this issue reviewed by Pharmacy2U, other online pharmacy and relevant regulatory bodies and changes implemented enhance patient safety. Specifically, we request easier, more effective means of communication and cancellation. Other industries have online electronic cancellation systems in place. It should be possible for the Pharmacy Industry to do this. We recognised this will come at a cost to them but potentially a huge saving to the NHS in terms of risk and cost. We deeply regret the circumstances surrounding Mr. Billings’ death and are committed to ensuring his legacy drives meaningful improvements in patient care. We trust that these measures demonstrate our commitment to addressing the concerns raised and our determination to prevent similar tragedies in the future. Should you require further details or wish to discuss our response, please do not hesitate to contact us. We also extend this invitation to the family of Mr Billings.

Dear Ms Luisa Nicholson,

RE: Regulation 28 Prevention of Future Deaths report for Mr Oliver James Billings, deceased.

We are writing to you regarding the report into the death of Mr Oliver James Billings dated 28th November 2024. We would like to express our sincere condolences to the family of Mr Billings for their loss.

The Royal Pharmaceutical Society (‘RPS’) is the professional leadership body for pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. Our role is to lead and support development of the pharmacy profession including the advancement of science, practice, education and knowledge in pharmacy. We transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 2010 and they now regulate pharmacy and pharmacy professionals in Great Britain.

In considering our response, we have sought input from our Expert Advisory Groups.

We acknowledge the conclusion from the inquest on 28th November 2024 that the death of Mr Billings was due to suicide and that the medical cause of his death was a result of the toxic effect of venlafaxine.

We also note the matters of concern in the report around:

1. Royal College of General Practitioners and RPS, 2024. Repeat Prescribing Toolkit [Online]. Available from:

2. France, H S., Aronson JK, Heneghan C. et al., 2023. Preventable Deaths Involving Medicines: A Systematic Case Series of Coroners' Reports 2013-22. Drug Saf [Online], 46. Available from: https://link.springer.com/article/10.1007/s40264- 023-01274-8 [Accessed 15 January 2025]

(1) That a subsequent prescription was submitted in the knowledge that the first was cancelled or to be cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that prescription before the subsequent prescription was issued. (2) That the swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied. (3) That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted.

Regulation 28 reports provide an opportunity for learning and actions to be taken by organisations to prevent further deaths. The RPS notes from a study published in 2023 looking at the preventable deaths, that one in five coroner-reported preventable deaths involved medicines. Common medicines involved were opioids, antidepressants and hypnotics. The RPS notes that coroners expressed concerns around the major themes of patient safety and communication, including minor themes of monitoring and communication between organisations.1,2

High risk medicines and vulnerable patients The recently published Royal College of General Practitioners and RPS Repeat Prescribing Toolkit1, advises GP practices to think carefully about their arrangements for repeat prescribing of medicines. Patients should be offered regular and careful review of their medicines and the decision to prescribe high-risk medicines should always be considered on an individual basis.

The RPS recognises that general practice and community pharmacies should ensure that all high-risk medicines, and particularly opioids, antidepressants and hypnotics, are treated carefully where they are to be prescribed as a repeat medication. The GP practice, the pharmacy and the patient all need to be clear about the arrangements for ordering and monitoring of such medicines as well as frequency of and purpose of a thorough, structured medication review.1 This may include discussions with the patient around suitability for accessing their prescribed medication via a distance- selling online community pharmacy.

The RPS would suggest to the coroner that this prevention of future death report is also shared with the Royal College of General Practitioners for wider shared learning.

Communication between healthcare providers The RPS notes from the coroner’s report that the cancellation of the EPS prescription by the GP practice to the distance-selling online community pharmacy was unsuccessful and that the GP practice was unable to get in contact with the pharmacy. We note that the report didn’t include details around attempts at

1. Royal College of General Practitioners and RPS, 2024. Repeat Prescribing Toolkit [Online]. Available from:

2. France, H S., Aronson JK, Heneghan C. et al., 2023. Preventable Deaths Involving Medicines: A Systematic Case Series of Coroners' Reports 2013-22. Drug Saf [Online], 46. Available from: https://link.springer.com/article/10.1007/s40264- 023-01274-8 [Accessed 15 January 2025]

communication from the GP practice to the distance-selling online community pharmacy.

The RPS believes that the onus should be on the prescriber and not the patient to contact the community pharmacy to discuss next steps in the event of an EPS prescription cancellation failure.

The RPS recognises that there needs to be clear routes of communication between the GP practice and the community pharmacy (including distance-selling online community pharmacies) to manage situations where EPS prescription cancellations have been unsuccessful.

NHS Digital have issued guidance on robust processes on EPS for healthcare providers.

Digital Functionality of EPS We have sought further information on the EPS system from our Digital Expert Advisory Group on the issue of EPS prescription cancellation.

An EPS Prescription Tracker tool is available to all NHS professionals who have a smartcard (which usually includes all prescribers and dispensers of EPS prescriptions) to allow them to check the status of an EPS prescription. The sharing of information via EPS between community pharmacies needs further consideration.

We understand that there is currently future development underway for a “Clinical Tracker” for EPS which will provide Health Care Professionals access to a patient’s EPS history, detailed products and dispensed status.

The RPS would suggest to the coroner that this prevention of future death report is also shared with NHS Digital for wider shared learning and comment on EPS.

Dispensing and supply of medicines from a community pharmacy The coroner’s report refers to the ‘swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied’. It is worth noting that under the NHS Community Pharmacy Contractual Framework Essential Service – Dispensing, there is a contractual obligation for community pharmacies in England to dispense medication for patients with reasonable promptness. Medicines optimisation is about ensuring that the right patient receives the right medicine at the right time. All assessments of the clinical appropriateness of a medication by a prescriber should be complete before issuing the prescription, therefore the subsequent benefits of a safe and timely supply of medicines would outweigh risks of supplying medicines efficiently.

1. Royal College of General Practitioners and RPS, 2024. Repeat Prescribing Toolkit [Online]. Available from:

2. France, H S., Aronson JK, Heneghan C. et al., 2023. Preventable Deaths Involving Medicines: A Systematic Case Series of Coroners' Reports 2013-22. Drug Saf [Online], 46. Available from: https://link.springer.com/article/10.1007/s40264- 023-01274-8 [Accessed 15 January 2025]

Thank you for highlighting your concerns in this prevention of future death report. We will consider how we can continue to raise awareness of these important issues through our future communications and engagement with the wider pharmacy sector. We will also raise these issues with our colleagues at the professional and representative bodies for pharmacy as they also play an important role in providing advice and support to the pharmacy professions.

Please don’t hesitate to contact us if you need anything further.

Dear HMC Nicholson,

Inquest into the death of Mr Billings (2024-0656) - Response to Prevention of Future Deaths (PFD) report

First and foremost, I would like to extend my deepest condolences to the family and friends of Mr Billings.

I note the following matters of concern raised in the PFD report:

(1) That a subsequent prescription was submitted in the knowledge that the first was cancelled or to be cancelled but that steps do not appear to have been taken or be able to be taken to ascertain the status of that prescription before the subsequent prescription was issued.

(2) That the swift dispatch of medication (whilst admittedly necessary in many circumstances) does not allow for mistakes to be noticed and/or remedied.

(3) That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted.

Response to concerns raised by HMC

The prescription was issued by the surgery directly to the NHS “spine” – the secure online database for electronic prescriptions - at 14:20 on 27 November 2023. We subsequently downloaded the prescription from the NHS spine at 14:21 on 27 November 2023.

It is pertinent to note that electronic NHS prescriptions do not pass from a surgery to a pharmacy directly – they are sent from the surgery to the spine, and then from the spine to the pharmacy (and then only when the pharmacy checks the spine for any prescriptions that may have been assigned to it).

The downloaded prescription was passed into our pharmacy system at 16:29, which allowed us to start our clinical processes (clinical check, labelling, assembly of the medicines, etc).

Following receipt of the PFD report, we have manually checked the tracking details of this prescription on the NHS spine. Pharmacies are not expected to do this at the time of dispensing a prescription, nor would it be practical to do so. We can now see that the surgery sent a cancellation message to the spine at 17:22, just over three hours after the prescription was originally issued.

Because we had already downloaded the prescription from the spine, the surgery’s attempted cancellation of the prescription from the spine was ineffective, and the surgery’s computer system would have indicated this to the surgery at the time, with a prompt to contact the pharmacy, which would have included our contact

details. In the absence of an attempt to contact us directly, we remained unaware of the surgery’s attempt to cancel the prescription.

A pharmacy that has already downloaded a prescription from the spine does not receive an electronic or automatic notification of an attempted cancellation by the prescriber. This is how the software for the Electronic Prescription Service was designed by the former NHS Digital (now NHS England, “NHSE”). NHSE would be able to explain in more detail, but I believe that it was considered to be an unacceptable risk to patient safety if a prescriber was able to send a cancellation message directly to a pharmacy that relates to a prescription that has already been downloaded by that pharmacy, as to do so may give the prescriber a false sense of security that the cancellation would in all cases be effective; when the prescription could be at any stage of the dispensing process in the pharmacy and the medicines may have already been handed out or sent to the patient. The prescriber might then make further prescribing decisions based on the false assumption that the prescription has been cancelled, when it may not have been possible for the pharmacy to do so; and it would undoubtedly also place an unreasonable burden on pharmacy teams to constantly check for such cancellation messages, as well as placing the burden of responsibility on the pharmacy to carry out the cancellation of the dispensing process when in many cases this would not be possible.

The cancellation of an electronic NHS prescription by a prescriber after it has already been issued and downloaded by a pharmacy is an exceptional situation and, we consider, should be treated as such, and dealt with by way of a personal communication between the surgery and the pharmacy, so the prescriber can accurately establish the dispensing status of the prescription at the pharmacy immediately and use that information to guide their subsequent decisions.

This is our understanding of how NHSE has designed the system: upon receiving a notification from the spine that its attempt to cancel a prescription has been unsuccessful, a surgery should manually contact the relevant pharmacy to discuss the intended cancellation, and the pharmacy’s contact details are displayed on the screen in the prescriber’s clinical system to enable them to make such contact. The relevant guidance on cancelling electronic prescriptions is available at:

service/cancelling-an-electronic-prescription

In the absence of direct contact, as described above, regrettably I consider that there are no reasonable steps which we could have taken to have established that the prescriber had attempted a cancellation of the prescription on the spine after we had downloaded it.

At 11:21 on 28 November 2023, we marked the prescription as “dispensed” on the spine, and the prescription was dispatched to the patient that day. The Royal Mail tracking information for the parcel is now unavailable due to lapse of time, but it was sent with a 48-hour service, so the earliest we expect it would have been delivered would have been 30 November 2023 (three days after it was prescribed). I understand the concern relating to the swiftness of the dispatch of the medicines, however I consider that our dispensing of the prescription was done with reasonable promptness and was no more swift than would have been anticipated from any other pharmacy.

The NHS Community Pharmacy Contractual Framework requires that NHS medicines and appliances are dispensed by registered pharmacies for patients on demand with “reasonable promptness” (Exhibit 1). I consider that it would be neither safe nor proportionate to introduce planned delays into pharmacy processes to allow a prescriber extra time to identify any post-prescribing concerns over and above those delays which are a natural part of a pharmacy’s existing processes.

As I have shown with our timescales above, it took several hours for our clinical processes to be completed and for the medicine to be dispatched in this case. In addition, the dispensing pharmacy has a responsibility to conduct a clinical and professional check of prescriptions, an aim of which is to identify concerns and resolve

them with the patient and/or prescriber before dispensing. However, in this case, we could not reasonably have identified that the prescriber wished to cancel the prescription in the absence of direct contact from them.

I have no evidence of contact from the surgery or the patient in relation to this prescription. The PFD report states that a matter of concern is “That the onus was on Oliver to remedy the error when Pharmacy2U could not be contacted”. I consider that it is incorrect to state that we “could not be contacted”, as we at all times remained available to be contacted. As a matter of good business practice, we continually review our inbound contact capacity and performance to ensure that anyone who wants to contact us can do so quickly and easily, and we will always continue to monitor this.

The NHS Directory of Services (https://digital.nhs.uk/services/directory-of-services-dos) is also available for healthcare professionals to access contact details for healthcare providers, in addition to those which are available to the general public.

In terms of actions that could be taken to prevent a recurrence of this situation:

1. I consider that there may be a need for all prescribers to be reminded of the applicable guidance highlighted above and the importance of making direct contact with a pharmacy if they wish to cancel an electronic NHS prescription that has already been issued and downloaded by a pharmacy, and to follow the instructions in their clinical system when it alerts them that the electronic cancellation was ineffective. This may be a matter for the professional leadership body for GPs.

2. I will also ensure that we continue to monitor our inbound contact channels and performance to ensure that we remain available for prompt inbound contact by anyone who needs to get in touch with us urgently for any matters.

3. I have also discussed this case with our senior clinical management team as part of our clinical review process and we will continue to work internally and with our healthcare colleagues in other parts of the NHS, as well as with groups such as the Community Pharmacy Patient Safety Group, to continue to improve patient safety and share learnings across organisations.

I am very sorry to have had to write to you in these circumstances and I again reiterate my condolences to the family and friends of Mr Billings.