Dyllon Milburn

16th July 2021 

Ref: REGULATION 28: 21 May 2021 (DM)  

Dear Mr Golomback,  

With regard to the Regulation 28 report dated 21 May 2021 (the “Report”), we were saddened to read 
of this incident. We treat such matters with the utmost seriousness and an internal review has been 
undertaken, focusing on the issue of repeat medications and compliance.  

Firstly, we reviewed the functionality available within EMIS Web and confirmed that it was working as 
designed and in a manner that complies with the system requirements specified by NHS Digital. 

On review of the patient’s electronic record, it appears that the patient had been inconsistent in terms 
of medication compliance since  commencing on Sertraline  in December 2018.  In the four months 
prior to being changed to electronic repeat prescriptions via EPS, the record shows that they had been 
non-compliant on a number of occasions, including 2 occasions where the patient failed to return to 
the GP Practice on time for a review and to obtain a further prescription.  On the first occasion, there 
was a delay of 20 days and on the second occasion, a delay of 14 days. 

The  patient  was  switched  to  repeat  prescriptions  on  11  July  2019  for  28-day  quantities.  On  the  2 
September 2019, when the patient requested the 2nd repeat prescription (approximately 24 days later 
than expected) the current and average percentage compliance with the repeat medication was as 
displayed below.  This was a further indication of under use of the medication and this should have 
alerted the GP practice to the fact that the patient was non-compliant with his medication. 

When a patient is placed on repeat prescriptions, the review date set is at the GP’s discretion (up to a 
maximum of 12 months).  This supports the benefits of repeat prescribing for both the patient and GP 
whilst allowing the GP to set an appropriate interval for review, depending upon the patient’s clinical 
presentation and compliance with treatment. 

On commencing the patient on repeat prescriptions, the GP confirmed a review date of 12 months. A 
shorter time frame for review could have been chosen which may have alerted the GP to compliance 
issues earlier. 

In addition, prescribers have the ability to check the status of a prescription using the NHS’s Electronic 
Prescription Service (EPS) Prescription Tracker.  This allows a prescriber to identify if EPS prescriptions 
have left the organisation, been downloaded by the dispensing pharmacy and/or been dispensed. 

 
 
 
 We  recognise  that  medicines  management  and  patient  compliance  is  a  highly  complex  area  for 
practices  to manage  given the  scale of repeat  prescribing each undertakes.   Practices should have 
robust policies in place to ensure that patients at risk through non-compliance are followed up and 
monitored closely; some practices will use other specific tools for at risk patients (e.g. diary entries or 
creating compliance reports) to help manage poor compliance.  Furthermore, prescribers have the 
ability  to  check  the  status  of  a  prescription  using  the  NHS’s  Electronic  Prescription  Service  (EPS) 
Prescription Tracker.  This allows a prescriber to identify if EPS prescriptions have left the organisation, 
been downloaded by the dispensing pharmacy and/or been dispensed.  However, use of such tools 
varies across different areas and practices.  

We are presently considering a number of potential digital tools that we could look to develop so as 
to aid further patient compliance.  

We agree that patients at risk present a specific challenge in terms of ensuring medication compliance 
and  would  welcome  a  discussion  with  the  profession,  NHS  England,  NHS  Digital  and  other  system 
suppliers to create best practice for primary care to help manage this risk. Enhanced, robust practice 
processes alongside new IT capabilities are likely to be needed and these can then flow through to the 
relevant NHS Digital functional specifications in order to ensure compliance nationally. 

We trust that the details outlined above are of help. 

Finally, as a company we work very hard to support health care services across the UK and patient 
safety  is  of  paramount  importance  to  us.  We  were  saddened  to  read  of  the  issues  relating  to  this 
particular incident and we would like to pass our condolences on to the family. 

If  you  have  any  further  queries  then  please  contact  our  Senior  Clinical  Director, 

  (via 

 in the first instance. 

Kind regards 

Dr 
Chief Medical Officer, EMIS Group

SUBMISSIONS  FOR  HM  CORONER  FOLLOWING  THE  INQUEST  HEARING  FOR 
DYLLON MILBURN  

At the hearing on 29 April 2021, HM Coroner Zak Golombeck, raised questions over the repeat 
prescribing  system  at  Bodey  Medical  Centre  (“the  practice”).  Dr 
  who 
appeared  at  the  Inquest  as  a  representative  of  the  practice  attended  a  meeting  with  her 
partners at the practice following the Inquest when there was a discussion about those matters 
which  HM  Coroner  asked  to  be  addressed.    In  providing  this  information,  Dr 
  has 
obtained  the  collective  views  of  her  three  partners  at  the  practice  who  endorse  these 
comments.    

1.  The current electronic software system and the details of the provider 

The practice software provider is EMIS Health. The version they use is EMIS Web and they 
use EMIS Web EPS (Electronic prescriptions Service) to prescribe at Bodey Medical Centre. 
The contact details the practice has for EMIS Health are:  

EMIS support at https://www.emishealth.com/about-us/contact-us/ 

Head Office 
Leeds - Fulford Grange  
Fulford Grange 
Micklefield Lane, Rawdon 
Leeds 
LS19 6BA 

or  
Regional offices 
Bolton - Aspinall House  
Aspinall House 
Aspinall Close 
Middlebrook, Horwich, Bolton 
BL6 6QQ 

There  are  three  methods  by  which  patients  of  the  practice  can  request  their  repeat 
prescriptions.  Firstly,  they  can  set  up  a  system  with  their  local  pharmacy  whereby  the 
pharmacy requests the patient’s medication on a monthly basis on their behalf. Secondly, the 
patient can set up online registration and request their medications online through the practice 
website.  Thirdly,  the  patient  can  fill  in  their  paper  repeat  prescription  slip  and  give  this  in 
manually either by giving it to one of the receptionists or by posting it in the repeat prescription 
slip box in the waiting room.  

For each of these options, a prescription request takes at most 2 working days for the practice 
to review, sign and process the prescription. This has to be done by a doctor or qualified nurse 
prescriber. The practice therefore asks their patients to request their repeat prescriptions at 
least 2 days in advance. The requirement for a 2-day processing time is prominently displayed 
on the repeat prescribing section of the website and on the repeat prescription slip boxes in 
the reception area at the practice.  

 
 
 
 
     
 
 
 
 
 
 
 
 
 
 
 In  this  case  the  patient  was  set  up  for  electronic  prescriptions  (option  2)  that  were  sent 
automatically to a pharmacy. If a patient wishes to change their nominated pharmacy, they 
can do so by either arranging this in their new preferred pharmacy, or if they inform the practice 
of a new preferred pharmacy, the practice can change the details on their system in EMIS.  

When an antidepressant is added to a repeat prescription, this is done in discussion with the 
patient  and  with  their  consent.  The  discussion  includes  how  to  take  the  medication,  the 
expected duration of the course and the need to wean off the medication. The patient is "safety 
netted" i.e. they are advised to seek a consultation with a GP if there is a problem with their 
medication at any time or if they experience a deterioration in their mental health.  

When  electronically  signing  a  repeat  prescription,  the  number  of  prescription  requests  are 
mapped on the system to the patient's daily quantity so there is a percentage estimate visible 
to the signing clinician which might indicate if the patient was not requesting their medication 
as they should be. When adding a new repeat medication on EMIS the prescribing clinician 
must  authorise  how  many  times  this  repeat  prescription  can  be  issued.  This  authorisation 
number indicates the maximum number of times the prescriber can issue that medication from 
the patient’s repeats before they need a review of that medication. The maximum time before 
each review would be for one year (i.e.12 issues of a 28 day quantity of medication might be 
authorised when initiating a repeat prescription for a medication if it was appropriate for this 
medication to be continued for 1 year).  

On  an  annual  basis  every  patient  has  a  medications  review.  This  also  applies  to  anti-
depressants on repeat prescriptions. At the annual medication review, the reviewing GP would 
routinely check that any repeats were being regularly collected. If they were not, appropriate 
action is taken which could involve removing the medication from repeats, and either swapping 
the medication from “repeats” to “acutes” or it could trigger a patient to be requested to come 
in for a review with a GP.  

2.  Comments on how an alert in the system would work in practice 

In  discussion  at  the  practice  meeting,  the  clinicians  commented  that  there  is  no  electronic 
system that they are aware of which can alert them as to whether a patient is not requesting 
their  repeat  medications  on  a  month-by-month  basis.  If  such  a  system  existed  and  were 
workable, there would need to be a protocol in place to clarify how the patient would be alerted 
to  this.  Possibilities  discussed  included  by  text  message  if  the  patient  consents  to  this,  by 
telephone (if so, the question arises as to who makes the call), or by letter for patients without 
access to phones (again raising the question as to who writes the letter). There would also 
need to be clarity as to what timeframe applied i.e. when such an alert would be triggered. 
What would be the appropriate timescale for alerting as to a late request for a prescription? 
Would this be days or weeks and if so, how many?. There would also need to be a protocol in 
place  to  detail  what  an  appropriate  response  would  be  when  such  an  alert  was  triggered. 
Given that an alert would have to apply to all medications to all patients across the practice, 
there are concerns about the volume of alerts that may be triggered and that the practice does 
not have sufficient resources to provide an appropriate response to such alerts either in terms 
of administrative or clinician staffing or time.  

Finally  it  would  seem  that  the  possibility  of  alerts  in  a  prescribing  system  would  have  far 
reaching consequences for GP practices nationally and that careful consideration would need 
to be given to the various medications issued on repeat prescription which are wide ranging. 
It may be that consultation with NICE is appropriate and any other relevant prescribing bodies 
in the UK.  

 
 
 
 
 
 
 
 
 , Legal Adviser, Medical Protection Society on behalf of Dr 

, 

Bodey Medical Centre  

12 May 2021

2nd Floor 
2 Redmond Place 
London 
E20 1JQ 
United Kingdom 

23 June 2021 

Zak Golombeck 
HM Senior Coroner 
Manchester City Area 

Our ref:  EH-315388 

Dear Mr Golombeck, 

I write in response to your regulation 28 report, dated 21 May 2021, regarding the 
death of Dyllon Shaun Graham Milburn. I would like to express my sincere 
condolences to Mr Milburn’s family. 

We have reflected on the circumstances surrounding Mr Milburn’s death, and the 
concerns raised in your report, in relation to NICE’s work. You suggest that an 
automated alert be added to the EMIS system to remind people to request and 
collect their repeat prescription to encourage compliance. While NICE is not able to 
influence changes to the EMIS system, the following NICE guidelines contain 
recommendations relevant to this report.  

In our guideline on medicines adherence: involving patients in decisions about 
prescribed medicines and supporting adherence (CG76), we recommend 
considering ‘using records of prescription re˗ordering, pharmacy patient medication 
records and return of unused medicines to identify potential non˗adherence and 
patients needing additional support’. 

We also recognise the importance of checking adherence in people being treated for 
depression in our guideline on the recognition and management of depression in 
adults (CG90). 

NICE produces tools to support implementation of our recommendations, but they 
are put into practice locally. Therefore, we do not consider that any action is required 
by NICE in response to your report. 

I hope the above information is helpful. Thank you for requesting our contribution.   

Yours sincerely, 

Professor 
Chief Executive

RC Royal College of
G P General Practitioners
J

Joint Honorary Secretary

Mr Zak Golombeck
HM Area Coroner for the Manchester City Area

14 July 2021
Dear Mr Golombeck,

Regulation 28 Report to Prevent Future Deaths - touching on the death of Dyllon Milburn

Thank you for your letter of 21 May 2021. | am responding on behalf of the Royal College of
General Practitioners as Joint Honorary Secretary to Council. Firstly, can! convey our
condolences to the family and friends of Dyllon Milburn. | was saddened to read of Dyllon's
passing.

The Royal College of General Practitioners (RCGP) is the largest membership organisation in the
United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of
general medical practice and to act as the ‘voice’ of GPs on issues concerned with education;
training; research; and clinical standards. Founded in 1952, the RCGP has just over 54,000
members who are committed to improving patient care, developing their own skills and
promoting general practice as a discipline.

NHS data shows that over 1.2 billion prescriptions are issued in England per year. Whilst
accepting that practices are of different sizes, with approximately 7000 GP practices in England
on average each is authorising over 170,000 per annum. Prescription errors are considered to be
common cause of complaint and potential litigation with rates of 8.9% and 4.9% in hospital
reduce this error rate and in general practice the almost universal use of computers and

hand written with little or no ability to audit how many prescriptions were being issued to an
individual patient, all GP IT systems are able to monitor whether a medication is being under or
over used. However, there is no visibility in general practice on whether a prescription is actually

Royal College of General Practitioners
30 Euston Square, London, NW1 2FB
regp.org.uk
Patrore HRH The Duke of Edinburgh (1972-2021) | Registered Charity Number 223106

collected or not. In the past, one of the main medical defence organisations, The Medical
Protection Society, did recommend a monthly meeting with the local pharmacy to ascertain what
prescriptions had been issued and not collected; the focus was particularly on patients with
psychosis such as schizophrenia. The underlying reasoning was that such individuals might be at
higher risk of self-harm. However, soundings | have had with other senior colleagues is that none
of currently do this, not least with the universal use of electronic prescribing, in many cases it
would not be feasible as prescriptions are frequently sent to a large number of pharmacies. To
compound matters, the IT systems that Pharmacies use are different to that in general practice.

Given the above, | recommend that RCGP opens a dialogue with our colleagues at the Royal
Pharmaceutical Society to consider this matter in more detail. As above, Medical Protection
Society has made recommendations in the past and clearly the clinical question remains.
However, since then, IT systems have become universal and the volume of prescriptions issued
annually has markedly increased. The RCGP view is that much greater integration of pharmacy
and GP IT systems will likely be needed, not least that any approach must be automated given
the scale of prescribing across the country.

| trust that this reply is helpful and if you have any questions, please do not hesitate to contact
me.

Yours sincerely,

Joint Honorary Secretary of Council
Royal College of General Practitioners

Cc: I esicient of royal Pharmaceutical Society