Debra Bates

60 ILKESTON ROAD, HEANOR, DERBYSHIRE, DE75 7DX 

TELEPHONE: 

   WEBSITE: www.parksurgeryheanor.co.uk 

Ms Sarah Huntbach 
HM Assistant Coroner for Derby and Derbyshire 
Town Hall 
Rose Hill 
Chesterfield 
S40 1LP 

By email only to: 

Dear Ma’am 

Inquest touching upon the death of Debra Bates: Prevention of future death report  

We are writing to provide our response to the Regulation 28 Report, received on 2 July 2024. 

Background 

27 August 2024 

At  the  time  of  her  death,  Ms  Bates  was  prescribed  14  medications  on  repeat,  which  included  three  controlled  drugs 
(
 but this was never issued on a repeat basis and 
always had to be authorised by a GP.   

).  She was also prescribed 

 and 

, 

In  April  2023, during  an admission to hospital following an  overdose, Ms Bates  was reviewed by  a Consultant  from  the 
Liaison Psychiatry Team who suggested that her regular prescriptions be supplied in blisters on a 3 days followed by 4 days 
cycle.   

This recommendation was discussed with Ms Bates’ pharmacist, but they declined to issue her medication in blister packs 
because historically she had not used blister packs appropriately, and there were concerns about putting controlled drugs 
into blister packs.  They also did not consider Ms Bates was a suitable candidate for medication delivery due to the risk of 
stockpiling medication.  They suggested non-blister 3 and 4 day prescriptions would be more suitable.  However, when this 
was discussed with the PCN Pharmacist, they were concerned that in this particular case (the addition of two sets of 14 
medications, including controlled drugs) could cause confusion and a risk of prescribing errors.  A decision was ultimately 
therefore taken to continue 7-day prescribing, in the absence of other safe solutions. 

Matters of Concern 

The main concerns in the Report to Prevent Future Deaths were expressed as follows: 

“No further investigation or inquiries were made as to how other practices implemented this [3 and 4 day] prescribing 
approach  in  a  case  where  there  are  multiple  medications  (including  controlled  drugs)  or  whether  /  what  safety 
measures  are  available  on  the  computer  system,  to  prevent  /  minimise  the  risk  of  the  wrong  prescription  being 
requested.” 

Action Taken   

We had an initial debrief at the Practice on 14 June 2024 to discuss the issues raised during the Inquest the previous day.  
We agreed that it should be possible to safely manage 3 and 4 day prescribing recommendations and that we would like to 
identify a solution / process to facilitate this.  We agreed to hold a more formal meeting on 14 July 2024 to discuss matters 
in more detail and to develop a Standard Operating Policy (SOP) for patients requiring 3 and 4 day prescriptions.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 60 ILKESTON ROAD, HEANOR, DERBYSHIRE, DE75 7DX 

TELEPHONE: 

   WEBSITE: www.parksurgeryheanor.co.uk 

The meeting on 14 July 2024 was attended by all five GP Partners and our Practice Manager.  We discussed the background 
as outlined above and agreed that we needed to develop an SOP to facilitate any future requests for 3 and 4 day prescribing.   

It was noted that two patients are currently prescribed medications in this way.  One patient was newly registered at Park 
Surgery  in March 2024 and  was already on a twice-weekly prescription regime,  which has been continued.  The second 
patient was requested to have twice weekly prescriptions on 14 June 2024 and this has been successfully implemented in 
collaboration with the duty GP and the PCN Pharmacist.   

We discussed a way in which we could implement safe prescribing and issuing of 3 and 4-days prescriptions. A key point 
was having  as  few  people as  possible involved  in the process to maintain  continuity.    Additionally,  since  each  drug  will 
appear twice on the repeat prescription list it must be clearly stated which day of the week each item should be issued on. 
Furthermore,  avoiding  prescriptions  being issued  on  Mondays  was  considered important  due  to Bank  Holidays and  the 
potential confusion this might cause.  We noted that ideally, prescriptions would be issued on Tuesdays and Fridays.  

We agreed that administrative staff, who normally issue repeat prescriptions, should not be involved in issuing medications 
for patients on 3 and 4-day prescriptions.  This is to reduce the risk of errors when issuing future-dated prescriptions for 
medications  where  each  item  appears  twice  on  the  repeat  medication  list.    We  noted  that  we  would  need  to  include  a 
reminder in the home screen for any patients on twice-weekly prescriptions, to alert staff that the patient is on twice-weekly 
prescriptions, and that we would create a READ code ‘Risk Reduction technique’ for audit purposes. 

We agreed the following actions: 

i. 
ii. 
iii. 

iv. 

v. 

vi. 

Practice Manager to create a READ code 
Prescribing Lead GP to draft SOP and review with the PCN Pharmacist and GP Partners 
Contact prescribing lead GPs in other local PCN Practices to enquire about experience with (and policies for) 
managing twice weekly prescriptions.   
Contact the ICB prescribing team to see if there is any guidance on issuing prescriptions more frequently than 
weekly. 
Contact the Community Mental Health Team (CMHT) to see if they have any policies regarding their processes 
for requesting 3 and 4-day prescriptions from GPs and also ensuring ongoing review of such patients, including 
whether there is a continuing need for twice-weekly prescriptions.   
Further Partners meeting to review progress arranged for 18th July 2024.   

Point (i) above was actioned on 16 July 2024 and the new READ code and home screen alert – “THIS PATIENT IS ON 3/4 
DAY SCRIPT REGIME.  ISSUES OR ADJUSTMENTS SHOULD ONLY BE MADE BY A CLINICAL PRESCRIBER” – were added to 
the notes for the two patients already receiving twice-weekly prescriptions.   

Point (iii) was actioned on 17 July 2024 with responses from four local practices.  Two Practices stated that they have no 
patients on twice weekly prescriptions.  One Practice stated they have two patients on twice weekly prescriptions that have 
been  stable  for  a  long  time  and  the  reception  team  manage  these  prescriptions.    One  Practice  advised  they  had  several 
patients on 3 and 4-day prescriptions, and they kindly emailed an outline of their process to us.  There were some valuable 
points in this, particularly around the patient's stock of medications prior to commencing 3 and 4-day prescriptions and 
dealing with patient holidays, which were incorporated into the Park Surgery SOP.  

Information  was 
intervals. 
ICB 
Prescribing_in_Primary_Care_Guidelines.pdf (derbyshiremedicinesmanagement.nhs.uk)  This was taken into consideration 
when writing the SOP, though there is no information specifically around prescription intervals of less than 7 days.   

prescribing 

regarding 

received 

(point 

from 

also 

the 

iv) 

A draft SOP was prepared and discussed with the PCN Pharmacist on 18 July 2024.   Amendments were made to remove any 
direct role for the PCN Pharmacists as they did not feel there was sufficient capacity within their team to respond in a timely 
manner to urgent requests.  The SOP was reviewed and agreed at the Partners meeting the same day.  The Lead GP for Mental 

 
 
 
 
 
 
 
 
 
 60 ILKESTON ROAD, HEANOR, DERBYSHIRE, DE75 7DX 

TELEPHONE: 

   WEBSITE: www.parksurgeryheanor.co.uk 

Health  also  confirm  that  they  had  had  a  preliminary  response  from  the  CMHT,  who  confirmed  that  they  would  look  to 
provide more information in due course.   

On  22  July  2024,  the  Practice  Manager  met  with  the  Reception  Manager  to  explain  the  SOP  regarding  3  and  4-day 
prescriptions – in particular that reception do not issue repeat prescriptions for patients on a 3/4 day script regime and any 
requests/queries about repeat issues or adjustments should be referred to a GP.  Pop-up alerts will be added for any patients 
on a 3/4 day script regime.  

We enclose a copy of the new SOP, which has been circulated to all staff.  The new process, in summary, is as below: 

  Any  requests  for  twice-weekly  prescriptions  are  passed  to  the  Duty  GP,  who  discusses  the  request  with  the 
requesting clinician if necessary and then speaks to the patient to explain the planned change and how it will work 
– that the GP will send prescriptions to the pharmacy for collection twice a week, usually on a Tuesday and Friday, 
with exceptions to 2 and 5 day prescriptions for longer bank holiday periods if necessary.  Prior approval from the 
secondary care clinician would be needed in advance for longer issues (i.e. to cover holidays abroad). 

  The Duty GP then sets up the 3 and 4 day prescriptions, noting which day of the week the 3-day supply should be 
issued (Tuesday) and the 4-day supply should be issued (Friday).  The prescriptions are then sent to the patient’s 
nominated  pharmacy  using  post-dated  electronic  prescriptions.    A  maximum  of  four  weeks  of  post-dated 
prescriptions can be issued, to ensure regular reviews by a clinician. 

  The Duty GP also adds READ code to the patient’s notes and the reminder to the home screen. 

  Any queries or issues with prescriptions must be passed to the Duty GP. 

Next steps and ongoing work 

1.  The next half-day education and training (QUEST) session at Park Surgery is on 18 September 2024, during which 
there will be an opportunity to reflect again on the SOP, answer any questions from the team and provide updates 
on any further information/advice from the CMHT.  

2.  We  are  also  planning  to  undertake  some  quality improvement  work  in relation  to  opioid  prescribing.   We  have 
already undertaken a review to identify any patients receiving high-dose opiates for non-cancer pain.  There are 3 
patients meeting this criterion and these patients will be reviewed with a view to reducing risk and opioid doses 
wherever possible.  From August 2024, one of our GPs and a GP Registrar will undertake a wider review of opioid 
prescribing  at  Park  Surgery.    This  is  likely  to  include  evaluation  of  data,  education  for  the  clinical  team,  de-
prescribing, discussion around resources for patients etc.  Although this work is likely to be ongoing, the time frame 
for the initial work is 12 months.  

3.  The SOP will be reviewed in July 2025. 

Conclusion 

We would like to again express our sincere condolences to Debra’s family and friends for their loss. 

We  hope  this  letter  demonstrates  and  provides  the  necessary  assurance  that  we  have  taken  the  concerns  raised  very 
seriously  and  taken  prompt  and  comprehensive  action  to  ensure  we  have  clear  and  robust  processes  in  place  to  safely 
manage similar prescribing requests/recommendations in the future.  As noted, this case has also prompted some wider 
quality improvement work around long-term opiate treatment, which we see as important work to better understand our 
prescribing and to facilitate opioid reduction where possible. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 60 ILKESTON ROAD, HEANOR, DERBYSHIRE, DE75 7DX 

TELEPHONE: 

   WEBSITE: www.parksurgeryheanor.co.uk 

We would be grateful if you could kindly confirm receipt of this letter and please do not hesitate to contact me if you require 
any further information.   

Yours sincerely