Margaret Feeney

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

13th February 2025 

Our ref: 

HM Coroner Peter Nieto 
St Katherine’s House,  
St Mary’s Wharf,  
Mansfield Road,  
Derby  
DE1 3TQ 

By email: 

Dear Mr Nieto,  

Thank you for the Regulation 28 report of 25th November 2024 sent to the Secretary of State 
for Health and Social Care about the death of Margaret Mary Feeney. I am replying as the 
Minister with responsibility for medicine regulation and prescribing.  

Firstly, I would like to say how saddened I was to read of the circumstances of  Margaret 
Mary Feeney’s death and may I offer my sincere condolences to their family and loved ones. 
The circumstances your report describes are concerning and I am grateful to you for bringing 
these matters to my attention. Thank you also for the additional time given to the Department 
to respond to the concerns raised in your report. 

The report raises the following concerns:  

• 

•  measures were/are not in place at Macklin Street Surgery and Daynight pharmacy in 
Derby to prevent prescription of excess medication to patients recognised to be at 
risk of overdose, either intentional or unintentional, who are ordinarily issued shorter 
period repeat prescriptions to reduce those risks;  
this situation arose/arises when early prescriptions are issued due to statutory holiday 
periods when most pharmacies are likely to be closed;  
there were/are no procedures in place relating to longer bank holiday periods (e.g. 
Easter) and;  
ineffective utilisation of electronic patient record and data systems 

• 

• 

I note that Derby and Derbyshire Integrated Care Board (ICB), Macklin Street Surgery and 
Daynight pharmacy are also recipients of this report and will be providing their own response 
to your report.  

You  outlined  in  your  report  that  Ms  Feeney  had  a  long  history  of  being  prescribed 
benzodiazepines and codeine and had become dependent on them. It is important to note 
that the decision to prescribe a particular drug is a clinical one and should be based on the 
patient’s  medical  needs.  Decisions  about  what  medicines  to  prescribe  are  made  by  the 
doctor  or  healthcare  professional  responsible  for  that  part  of  the  patient’s  care  and 

 
 
 
 
 
 
 
 
 
  
 
 
 prescribers are accountable for their prescribing decisions, both professionally and to their 
service  commissioners.  Clinicians  should  work  with  their  patient  and  decide  on  the  best 
course  of  treatment,  with  the  provision  of  the  most  clinically  appropriate  care  for  the 
individual always  being  the  primary consideration.  Clinicians must take  into  account  best 
prescribing  practice  and  the  local  commissioning  decisions  of  their  respective  integrated 
care  boards  (ICBs)  as  well  as  appropriate  national  guidance  on  clinical  and  cost 
effectiveness. Pharmacists are also expected to use their judgement to make sure that any 
prescription  they  dispense  is  clinically  appropriate.  The  pharmacist  may  decide  to  delay 
dispensing pending further consultation with the patient and/or prescriber where concerns 
arise. 

The  General  Medical  Council  (GMC)  is  the  regulator  of  all  medical  doctors,  anaesthesia 
associates (AAs) and physician associates (PAs) practising in the UK. It sets and enforces 
the standards all doctors, AAs and PAs must adhere to. The GMC has published guidelines 
on good practice in proposing, prescribing, providing and managing medicines and devices. 
GMC  guidance  states that  when  prescribing controlled  drugs  and other medicines  where 
additional safeguards are needed, doctors should propose, prescribe or provide a limited 
quantity and dose – one that is sufficient to make sure the patient receives suitable care 
until  a)  they  are  able  to  see  an  appropriate  health  professional  who  has  access  to  the 
relevant  information  from  their  medical  records  or  b)  the  doctor  is  able  to  verify  that 
information themselves.  

At a national level NHS England has a clear responsibility in providing systems oversight for 
the management and use of controlled drugs, including benzodiazepines and opioids. NHS 
England’s Controlled Drugs Accountable Officers (CDAOs)1 undertake this role within each 
geographical  region  across  England.  They  provide  assurance  that  all  healthcare 
organisations,  including  pharmacies,  adopt  a  safe  practice  for  appropriate  clinical  use, 
prescribing, storage, destruction and monitoring of controlled drugs.  

CDAOs facilitate the routes to share concerns, report incidents, and take remedial action as 
well  as  highlighting  good  practice.  This  is  shared  with  wider  partners  such  as  Clinical 
Commissioning  Groups  and  the  Police  through  the  Controlled  Drugs  Local  Intelligence 
Networks (CD LINs). Details of all CDAOs in England are held on a national register, which 
is owned and published by the CQC: www.cqc.org.uk/content/controlled-drugs-accountable-
officers. 

In March 2023 NHS England published ‘Optimising personalised care for adults prescribed 
medicines associated with dependence or withdrawal symptoms : Framework for action for 
ICBs and primary care’. The framework includes five actions, resources and case studies to 
help systems develop plans that can support people who are taking medicines associated 
with dependence and withdrawal symptoms including benzodiazepines and opioids by:  

•  Optimising  personalised  care  for  adults  prescribed  medicines  associated  with 

dependence or withdrawal symptoms. 

 1 https://www.england.nhs.uk/contact-us/privacy-notice/how-we-use-your-
information/safety-and-quality/controlled-drugs-accountable-officer-alerts-etc/ 

 
 
 
 
 
 
 
 
 
 
 
 
 • 

Informing  ICB  improvement  and  delivery plans,  when  commissioning  services  and 
developing local policies that offer alternatives to medicines in the first place and/or 
support patients experiencing prescribed drugs dependence or withdrawal.   

•  Ensuring a whole system approach and pathways involving multiple interventions, to 
improve  care  for  people  prescribed  medicines  associated  with  dependence  and 
withdrawal symptoms. 

As you may be aware, the National Institute for Health and Care Excellence (NICE) is the 
independent  body  responsible  for  translating  evidence  into  authoritative  evidence-based 
guidance for the health and care system on best practice to drive improved outcomes for 
patients.  Guidelines  describe  best  practice  and  NHS  organisations  are  expected  to  take 
them fully into account in designing services that meet the needs of their local populations. 

NICE has published guidelines on: 

•  Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and 

management of chronic primary pain 

•  Medicines  associated  with  dependence  or  withdrawal  symptoms:  safe  prescribing 

and withdrawal management for adults.  

The  National  overprescribing  review  report  was  published  in  Sept  2021,  it  evaluated  the 
extent,  causes  and  consequences  of  overprescribing  and  made  20  recommendations  to 
address it. NHS England and partner organisations have been implementing the review’s 
recommendations over the past 3 years, aiming to achieve long term sustainable reductions 
to overprescribing via delivery of systemic and cultural improvements within the NHS.  

You may find it helpful to know that a number of interventions are being delivered by NHS 
England to address and reduce overprescribing including: 

o  Publication of the National medicines optimisation opportunities for the NHS in 2024/25, 
which includes an opportunity on chronic non-cancer pain management without opioids. 
ICBs are encouraged to select opportunities for delivery. 

o  Support for delivering Structured Medication Reviews (SMR), including: 

•  NHSE contract for Primary Care Networks specifies use of SMRs for high-risk groups 
of  patients.  It  also  specifies  using  medicines  optimisation  strategies  for  reducing 
polypharmacy,  minimising  risk  of  prescribing  harm,  reducing  overprescribing  and 
managing the risk of dependency on prescription drugs. 

•  Funding  of  Clinical  Pharmacists  through  the  Additional  Roles  Reimbursement 
Scheme (ARRS). to support the primary care team with medicines optimisation and 
carry out SMRs.   

•  Further NHSE guidance advising that high-risk groups should be prioritised for SMRs, 
including  those  on  prescribed  medicines  that  may  cause  dependence  and 
withdrawal. 

 
 
 
 
 
 
 •  Training and education for prescribers to help build GP and prescribing health care 
professionals' confidence in, and understanding of, the complex issues surrounding 
stopping inappropriate medicines safely. 

•  Patient facing materials to help patients and carers prepare for an SMR. 

o  A  national  programme  to  offer  non-pharmacological  alternatives  such  as  social 
prescribing,  as  well  as  funding  for  social  prescribers  through  the  ARRS.  Social 
prescribing  is  demonstrated  to  support  patients  address  wider  determinants  of  health 
which may be an underlying or contributory factor to the inappropriate use of medication. 

o  Publication of the RPS and RCGP Repeat prescribing toolkit, commissioned by NHSE 

to improve repeat prescribing processes.  

o  Publication of the Oversupply Dashboard to support general practice and primary care 

networks identify oversupply and target improvements.  

The NHS Medicines Safety Improvement Programme (which forms a key part of the NHS 
Patient  Safety  Strategy)  is  also  delivering  a  focussed  programme  of  work  relating  to  the 
improved care of people with chronic pain and a reduction in the use of prescribed opioids. 
The  programme  has  been  in  place  since  January  2021.  The  national  programme  is 
supporting Integrated Care Systems to learn from, adapt and adopt effective practice using 
a whole-system improvement approach. 

In  2022/23  18  Integrated  Care  Systems  received  intensive  support  to  develop  and 
implement improvements in care and a further 15 are participating in shared learning events. 

Commissioning of services to support people with chronic pain (including services to support 
people  to  safely  withdraw  from  prescribed  medicines  that  may  cause  dependence  and 
withdrawal)  now  lies  with  Integrated  Care  Boards  (ICBs).  NHS  England  expects  ICBs  to 
commission  appropriate  services  to  meet  the  needs  of  the  population  that  the  ICB 
geographically  covers.  This  includes  taking  due  regard  to  any  of  the  above  national 
commissioning or clinical guidance.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,  

MINISTER OF STATE FOR HEALTH

Regulation 28 Report to Prevent Future Deaths
Derby and Derbyshire Integrated Care Board Response

Derby and Derbyshire Integrated Care Board (DDICB) would like to extend our
sympathies to the family and friends of Margaret Feeney. Please find below the ICBs
response and future plans in regard to the Regulation 28 Report to Prevent Future
Deaths.

If there are any areas which you feel you would like more information or to discuss in
person this will be arranged.

On 11 April 2024 the coroner commenced an investigation into the death of Margaret Mary
Feeney aged 78. The investigation concluded at the end of the inquest on 11 November
2024.  The conclusion of the inquest was that: –

Margaret died due to taking excess prescribed medication which she had become
dependent on and addicted to. She had access to excess medication because of medical
prescribing decisions and arrangements leading up to a bank holiday period.

Margaret was found deceased at her home address on 1 April 2024 by her friend and
cleaner. She had last been spoken to in a telephone call on 30 March 2024.

Post-mortem examination with toxicology identified the medical cause of Margaret’s death
as the combined toxic effects of prescribed medication which she had taken in excess.
She was also identified to have pneumonia which contributed to her death. A high total
morphine level suggests the potential additional taking of a morphine-based substance.

Margaret had a long history of being prescribed benzodiazepines and codeine, the latter
medication for pain for diagnosed conditions. Unfortunately Margaret had become
dependent on those medications and was recognised to overuse them. As a
consequence, she was given seven-day prescriptions.

On 26 March Margaret’s friend was concerned that Margaret was confused, and the friend
and Margaret attended a GP appointment that afternoon. The GP wanted to reduce
Margaret’s diazepam and issued a prescription for a lower dose in a daily dose blister
pack. The codeine prescription was not altered. The new diazepam prescription was with
Margaret on 27 March. This was the week prior to the Easter holiday period. Margaret had
received her usual Monday prescription (25 March) including diazepam and codeine. With
the new diazepam prescription received on 27 March Margaret had an excess of five days
of that drug. Because of the pending bank holiday Margaret received an early prescription
of codeine on 28th March, which meant she had four days excess codeine.

Clearly, given her recognised dependence and overuse, there was a real and foreseeable
risk that Margaret would take excess diazepam and codeine that was available to her
between 27 March and her death. In addition to the toxicological evidence, when she was
found deceased there were empty or near empty blister packs from the excess medication
prescribed to her.

On the evidence there is no reason to consider that Margaret had deliberately taken the
excess medication to cause her own death.

 The following report and action plan is in response to the matters of concern revealed
through the course of the inquest as below. The concerns have been reviewed with
actions to prevent future deaths captured in the action plan at the end of the report. This
will be reviewed as per the timescales included within the report.

Coroner concerns

I am concerned that measures are not in place at Macklin Street Surgery and Daynight
pharmacy to prevent prescription of excess medication to patient’s recognised to be at risk
of overdose, either intentional or unintentional, who are ordinarily issued shorter period
repeat prescriptions to reduce those risks. This situation arises when early prescriptions
are issued due to statutory holiday periods when most pharmacies are likely to be closed.
I have been informed that measures have been introduced to prevent excess prescribing
by taking account of single day bank holidays, but there are no measures relating to
longer bank holiday periods (e.g. Easter). With electronic patient record and data systems
it seems a reasonable presumption that suitable solutions can be identified.

As I imagine that the substance of my concern is likely to apply to other GP practices and
pharmacies, I have also sent this report to the Department of Health and Social Care and
NHS Derby and Derbyshire Integrated Care Board.

Derby and Derbyshire ICB Response

Having reviewed your report and the outlined circumstances, DDICB recognises the
serious implications of the matters raised. Addressing the concerns you have highlighted
is a priority for the ICB, and are committed to taking steps to minimise the risk of similar
incidents in the future.

Good Practice

Effective management of at-risk patients is critical to preventing harm and improving
outcomes. In this case, several good practices were evident and should be acknowledged
as part of the ongoing commitment to patient safety. These measures provide a foundation
for further improvements and system-wide learning.

 The patient was appropriately identified as having a dependence on certain

medications and was managed with:

o Weekly prescriptions to minimise the risk of overdose.
o A prompt review by a prescriber immediately after side effects (confusion)

were reported.

 We have reached out to Macklin Street Surgery to support any actions they

identify. Our aim is to share learning across the system to enable the scaling of
improvements. Although we have not yet received the investigation summary, our
offer of support has been acknowledged, and we await their response after their
coroner's response is finalised. Additionally, due to the nature of the medications,
the ICB has engaged with the NHS England - Midlands Controlled Drugs Area
Team who have volunteered to liaise with the Community Pharmacy and to share
their response when available.

 Resources

A range of resources are available to support healthcare providers in managing high-risk
medications and ensuring safe prescribing practices. These tools and initiatives aim to
equip teams with the knowledge and frameworks needed to reduce harm and improve
patient outcomes, particularly in cases of opioid stewardship and medication dependency.

 Opioid Change Management Programme:

A collaborative project between Joined Up Care Derbyshire and Health Innovation
East Midlands, providing tools for opioid stewardship:

o Quality Improvement Toolkit: A resource for practices to implement opioid
prescribing quality improvements, aligned with the National Medicines
Safety Improvement Programme.

o Minimum Standards for Opioids Repeat Prescribing: Guidelines for

practices to develop robust repeat prescribing processes while maintaining
safety and quality standards.

o Opioid Tapering Resource: A concise guide to support opioid reduction

efforts.

 Clinical System Searches: Tools available across all utilised GP systems to assist

in identifying at-risk patients and supporting optimised management.

Process Updates

Ensuring that robust and flexible processes are in place is essential to managing atypical
situations, such as those arising during extended bank holiday periods and when there is
a change in prescribed medicines required (such as this case with identified side effects).
Process improvements should prioritise patient safety while minimising disruptions to
established routines. Outlined are proposed updates that are to be shared with all GP
practices to enhance continuity of care and safeguard against future risks.

 Prescription Scheduling Adjustments:

o Practices to change processes for prescription collection dates for patients
with regular collection schedules to mid-week (e.g., Wednesday) to avoid
clashes with bank holidays and minimise re-scheduling to manage
prescription collections during extended bank holiday periods.

 Consider Patient-Specific Needs:

o Patients with more frequent collection schedules (e.g., twice weekly) should
have these routines considered during changes to prescription dates or
new patient management plans.

o Interim or one-off acute prescriptions must also account for existing

schedules to avoid overlaps or gaps.

 Acknowledge Atypical Prescribing Situations:

o Assess patient routines and the potential impacts of changes to prevent

adverse effects, particularly on vulnerable individuals.

 Utilisation of NHS EPS (electronic prescribing system) prescriptions

Clinical systems are integral to supporting safe prescribing practices and ensuring clear
communication between healthcare providers. Leveraging available system functionalities
can enhance the management of high-risk medications and prevent issues arising from
unconventional prescribing scenarios.

One key functionality within the NHS Electronic Prescribing System (EPS) is the ability to
post-date and schedule prescriptions to download only on specified dates. This feature
reduces the likelihood of prescriptions being dispensed ahead of time, particularly during
extended bank holiday periods, where excess medication might otherwise be provided
inadvertently. These prescriptions can also be cancelled ahead of time to prevent
inadvertent dispensing – useful in the event of medication changes.

We recommend promoting the use of this feature across all practices as part of a broader
effort to strengthen the scheduled prescription process. Sharing this learning with system
users can help make prescription management more robust and prevent potential
medication-related risks.

Communication of changes / updates

 Communication with Providers:

o Notify community pharmacy immediately of medication changes, especially

for high-risk patients or medications with significant harm potential.
o Establish clear dialogue during consultations to align on prescription

collection schedules and current patient stocks.

 Patient and Caregiver Engagement:

o Clearly communicate any changes to medication or collection schedules to

the patient and/or their caregiver to ensure understanding and avoid
inappropriate use.

 Shared Care Records:

o Ensure shared care records are updated promptly to reflect any changes in

patient management.

Clinical system updates

We acknowledge that updates to provider clinical systems could play a crucial role in
addressing the issues identified. However, given the operational and developmental
oversight of these systems lies with their respective clinical system providers, we believe
they are best positioned to evaluate and enact the necessary changes.

As these changes are likely to involve system-wide implications and require alignment
with broader national or regional policies. We will share our learning and concerns with
clinical system providers with a request to consider and implement solutions that may
prevent further occurrences.  It may be most effective if the coroner were to also engage
directly with the clinical system providers. This direct communication would allow the
coroner to convey their concerns comprehensively and advocate for updates grounded in
the findings of this case, ensuring a coordinated and impactful response.

Learning to Be Shared Across the System

Sharing the lessons learned from this case with stakeholders across the healthcare
system is essential to fostering a culture of continuous improvement. By disseminating

 these insights and recommendations, we can ensure that the entire system benefits and
that similar incidents are less likely to occur in the future.



Identify At-Risk Patients:

o Proactively flag and monitor patients vulnerable to medication dependency

or overdose risks.

 Strengthen Provider Communication:

o Ensure timely updates between healthcare providers, particularly around

patient management changes.

 Assess Bank Holiday Arrangements:

o Recognise and plan for bank holiday disruptions well in advance to mitigate

risks.

 Consider EPS prescriptions (post dated)

o  This would reduce the likelihood of prescriptions being issued ahead of time

To ensure system wide uptake and action, the ICB will ensure engagement and cascade
through the following channels; 

-  Community Pharmacy Derbyshire Newsletter
-  GP Key messages delivered to practices by the ICB Pharmacy Directorate team
- 
-  Prescribing Leads Forums

ICB Pharmacy Directorate Team Medicines safety messages shared with practices

Please see below a timeline of proposed actions

Action number

1a

1b

2a

Proposed completion date

Overview of DDICB
actions
INVESTIGATION AND SUPPORT
Review investigation and
lessons learnt/ actions
identified by the practice.
With support of the ICB
primary care quality team
and ICB patient safety team,
identify support required
Review investigation and
lessons learnt/ actions at
community pharmacy. With
support of Midlands
controlled drugs area team
and primary care
commissioning team, identify
support required.

7/2/25

7/2/25

REVIEW AND COMMUNICATIONS

14/2/25

Extract shared learning from
the practice and community
pharmacy reports and add
lessons to be shared
additionally to those raised
above, into an incident
report, ready to be shared
with system colleagues.
Learning report ratified

 2b

2c

through existing governance
routes
Collated learning to be
shared through existing
communications as identified
above.
At the Clinical Governance
Leads meeting with general
practice the Learning report
will be discussed as part of
the Patient safety standard
agenda item.

Following Derbyshire
Prescribing Group (DPG)
6/3/25.

Following Derbyshire
Prescribing Group (DPG)
6/3/25.

Partners:

Associate Doctors:

S

Manager:

Macklin Street Surgery
90 Macklin Street
Derby       DE1 1JX
Telephone:  01332 340381

Branch:
Park Farm Surgery:

Park Farm Drive

Allestree, Derby, DE22 2RP

Telephone:  01332 551021

Private & Confidential
Mr P Nieto
Senior Coroner for Derby and Derbyshire

By email: 

Dear Mr Nieto,

Prevention of Future Deaths Report concerning Mrs Margaret Feeney.

I write as the Senior Partner at Macklin Street Surgery further to the Inquest into the death of Mrs Feeney that took place

on 11 November 2024 and following receipt of your Prevention of Future Deaths Report dated 25 November 2024. You

have raised concerns as to the issuing of prescriptions around bank holidays for patients who have been placed on shorter

repeat prescription periods with the aim of reducing the risk of overdose.

A large number of the patients at the surgery who have been placed on shorter repeat prescriptions are given 7-day

prescriptions.  This means that they will only be given 7 days’ worth of medication for each prescription. Historically, those

prescriptions were issued and sent to a patient’s chosen pharmacy to dispense on a Monday. This was the case with Mrs

Feeney.  A smaller number of patients are likely to opt to collect a paper copy of their prescription from the surgery to take

to their chosen pharmacy. However, as identified this means that when a bank holiday falls on a Monday, the prescription

has to be issued on the immediately preceding working day so that patients are still able to access their medication.

Usually this would be a Friday but in Mrs Feeney’s case, because of the Easter weekend (and the Friday also being a bank

holiday), the prescription was brought forwards to the Thursday.

Whilst the surgery could facilitate the issuing of prescriptions on a bank holiday as these could be future-dated,

pharmacies are not routinely open on a bank holiday. As such, if the day for the 7-day prescriptions was not moved when

a bank holiday arose on a Monday, patients would be unable to access their medication, which could have significant and

life-threatening consequences. A number of the patients who are on 7-day prescriptions are receiving such prescriptions

for opiate drugs and/or benzodiazepines. If a patient being prescribed these drugs is unable to access a prescription due

to a bank holiday and therefore suddenly stops taking this medication, they may suffer acute withdrawal symptoms. The

consequences of this can be severe and so the risk of this has to be balanced against the risks associated with a patient

1

 having access to an additional few days of medication. Whilst some pharmacies may be open on a bank holiday, it is our

experience that the majority are not and which pharmacy is open may differ between the bank holidays. Patients are free

to choose which pharmacy they would like their prescriptions to be sent to and so prescriptions from the surgery will be

sent to various pharmacies in the area depending on the particular patient’s preference. Having looked into whether there

are any pharmacies that are routinely open on bank holidays, I have located one in the area within a supermarket but it

does not appear it is open on Christmas Day and it would not be conveniently located for a number of our patients. It

would not be possible for the surgery to require patients on 7-day prescriptions to elect to use that pharmacy.

In light of Mrs Feeney’s death, the practice conducted a significant event analysis on 8 August 2024 and a copy of that

report has been shared with you previously. As part of that review, it was identified that a way of minimising the need to

bring forward 7-day prescriptions prior to bank holidays (and therefore reduce the risks associated with patients having

additional medication) was to move the day on which 7-day prescriptions were issued. We initially considered changing the

issuing day to a Wednesday but we have since decided to move the day of issue to a Tuesday.

The surgery has now identified all patients who are on short-term prescriptions (which we have defined as having a

prescribing period of 14 days or less) and the prescription day for all of these patients has been moved to a Tuesday.

Patients and pharmacies have been advised.  An alert has also been placed in the patients' notes. We are implementing a

rolling alert so that a clinician will be alerted if a patient moves onto short-term prescriptions in the future.

The surgery is currently in the process of ensuring that the notes of all of the patients who have been identified as being on

short-term prescriptions are reviewed by a clinician to assess whether each patient is at high or low risk. However, risk is

broader than risk of overuse / overdose. Risk includes risk of medication harm, (that is to say, some drugs would present a

greater risk of harm than others if overused or taken in overdose). Therefore, a clinician will determine whether a patient is

at high or low risk of harm if the patient takes more than their prescribed dose. This will be reviewed at the annual

medication review.

Now that all short-term prescriptions have been moved to a Tuesday, the issue of having to alter prescription processes

will only arise on the years when Christmas Day, Boxing Day or New Year’s Day fall on a Tuesday. If Christmas Day,

Boxing Day or New Year’s Day fall on a Tuesday, the prescriptions for those patients who have been identified by a

clinician as being at high risk will be split i.e. the prescription week will be divided so that those patients will receive two

shorter prescriptions to cover them for the bank holiday. How the prescription will be split will depend on how the bank

holiday falls but could take a 3:4 day format thus minimising the risks as far as possible. Unfortunately, it is not possible for

the surgery to mitigate risk entirely because of the fact that pharmacies are not routinely open 7 days a week including on

all bank holidays and because patients, understandably, have the freedom to choose which pharmacy they would like their

prescriptions sent to. As you have identified, this is not an issue that is likely limited to Macklin Street Surgery but is one

that is likely to affect all GP surgeries across the country. It should also be appreciated that there are some technical

constraints to the digital records system the practice uses (SystmOne) and the reports it is able to generate. This includes

clinicians not being able to generate data regarding the total quantity of medication prescribed (tablet strength x quantity

of tablets) without extracting data into an exported spreadsheet and SystmOne not being able to report on the duration of

prescriptions. Rectification of this is something that would need to be addressed at a national level with the system supplier

and NHS Digital.

2

 The policy will be included in induction and locum packs. Training will be offered at induction for reception staff / new GPs /

locums / GP registrars. The prescribing team will maintain a log of staff trained.

The surgery will write to the Integrated Care Board seeking advice on how we use the ICB system's central clinical

pharmacy / medicines management expertise to assist practices with the management of high-risk patients. We will liaise

with the Integrated Care Board to determine how our learning from this experience could be shared with other local GP

surgeries to assist them in improving their processes around short-term prescribing. We will also highlight to the ICB any

potential national level digital constraints.

I hope that the above clarifies the situation, reassures you that the surgery has taken this matter seriously and that we are

doing everything we can to reduce this risk within the limitations of which we much necessarily work.

Yours sincerely

Senior Partner
Macklin Street Surgery

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