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An uncollected prescription

01 July 2019

This inquest case took place in the United Kingdom, and refers to some processes of local relevance

Mr A, who was 77 years old, had a history of dementia, diabetes mellitus, hypertension, ischaemic heart disease and severe chronic obstructive airways disease (COPD), for which he was on long-term oxygen therapy. He was a resident in a care home.

Mr A was seen by Dr P, a GP, and presented with fever and a cough that was productive of green sputum. Dr P diagnosed an infective exacerbation of COPD and prescribed antibiotics. He advised the care home staff that the practice would contact them when the prescription was ready to collect later that day. Dr P generated the prescription when he returned to the practice and the reception staff called the care home that afternoon.

The prescription was never collected and Mr A died four days later. The cause of death was identified as bronchopneumonia due to COPD.


An investigation began into the death of Mr A, and the coroner obtained statements from a pathologist, Dr P, the care home manager, the daughter of Mr A, and a healthcare support worker. The statements highlighted a conflict between the GP surgery and the care home staff, in relation to whether the care home was notified that the prescription was ready for collection.

In light of the concerns surrounding the issuing and collection of the antibiotics and its impact on Mr A’s death, the coroner decided to hold an inquest. Both the GP practice and the care home were identified as interested persons, and two witnesses were called: Dr P and the care home manager.

Through Dr P’s oral evidence, it was clear that the practice had appropriately issued the prescription. There was a note in the medical records that reception staff had contacted the care home to notify them that the prescription was ready for collection at 14.15. However, there was no record of which member of the care home staff they spoke to.

The care home manager conducted an investigation in relation to this. They were unable to identify from those working that afternoon who the practice had spoken to, as there was no record of the telephone call.

As a result of the incident, the practice conducted a significant event analysis (SEA) investigation. Through this, they implemented changes in how they communicated with care homes and how they dealt with uncollected prescriptions.


The coroner returned a conclusion of natural causes. In his summing up, he determined that although earlier administration of antibiotics may have lessened Mr A’s symptoms, it was unlikely – given the severity of his COPD and other comorbidities – to have prevented Mr A’s death.

As the practice had already carried out an SEA and made improvements to the practice systems, the coroner did not issue a Regulation 28 report.[i] He recommended that the care home review its systems in relation to the collection of prescriptions for residents.

How Medical Protection helped

Dr P was a member of Medical Protection and made contact when he received the request from the coroner for a statement. Medical Protection helped Dr P to draft his statement and recommended that the practice carry out an SEA investigation.

When the practice was confirmed as an interested person, Medical Protection instructed legal representation to represent Dr P’s interests at the hearing, obtained disclosure of relevant documents from the coroner and prepared Dr P for giving evidence. He had not given evidence at an inquest before so found the prospect of attending quite daunting.

Dr P’s clear and detailed statement assisted him during his oral evidence, and demonstrated to the coroner and the family that the appropriate steps had been taken to prevent a similar incident in the future.

Dr P felt reassured and supported by Medical Protection, which gave him confidence during his oral evidence. Dr P was not criticised by the coroner, avoiding the need to self-refer to his regulatory Medical Council.

[i] In the UK, a Regulation 28 report sets out the concerns raised in a coroner’s investigation and requests that action should be taken. All Regulation 28 reports and the responses are sent to the chief coroner.