Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0055, written 31 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 31 Jan 2025 |
|---|---|
| Reference | 2025-0055 |
| Deceased | Kim Robinson |
| Coroner | Nigel Parsley |
| Coroner area | Suffolk |
| Category | Alcohol, drug and medication related deaths · Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State Department of Health and Social Care 1 CORONER I am Nigel PARSLEY, HM Senior Coroner for the coroner area of Suffolk 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 13th May 2024 I commenced an investigation into the death of Kim Jeanette ROBINSON The investigation concluded at the end of the inquest on 28th January 2025. The conclusion of the inquest was that the death was the result of:- Suicide The medical cause of death was confirmed as: 1a toxicity 4 CIRCUMSTANCES OF THE DEATH Kim Robinson’s death was recognised at 05:16 on 12th May 2024, at her home address in Suffolk. Kim had suffered for many years with chronic and debilitating leg and back pain, for which she took prescribed medication. Kim also suffered with her mental health and had previously taken overdoses of her prescribed medication. Toxicological analysis identified that Kim had the drug anxiety, heart and blood pressure medication) significantly above the toxic level. in her system (an Kim was not prescribed obtained a supply from an on-line pharmacy. at the time of her death by her usual GP, but had In order to obtain rather than her correct details. The process required to do this was described as a ‘tick- box’ exercise in court. on-line Kim ensured she supplied the required details, When the online prescription was made (6th May 2024), the prescribing clinician had no access to Kim’s online GP records. Regulation 28 – After Inquest Document Template Updated 30/07/2021 Evidence was heard that had access to Kim’s GP records been available to the prescribing clinician, the prescription of would not have been made. Evidence heard in court identified that Kim’s normal prescriptions were secured by a loved one, who controlled the amounts of prescription medication Kim could access at any one time. When delivered, the package containing the providing her direct access to a fatal quantity of prescription medication. was addressed to Kim, Had the online prescription not be made, Kim’s death would not have occurred. 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters given rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you; the MATTERS OF CONCERN as follows. – 1. Following Kim’s tragic death the GP who had prescribed the prescription of to Kim, reviewed the current online system in place and identified five areas where in his evidence he identified changes could be made. The GP stated there was:- a) The need for online prescribers to be able to access a patient’s records (at least the Summary Care Records). These records could be attached to the consultation for review by the prescriber. b) All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. When consent is given, it was suggested a notice should be sent to these healthcare providers at the same time the medicine is delivered to the patient. Without such consent, the patient’s order should not be accepted. c) Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed. d) All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” e) Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies. Had these features been present on the on-line system, the GP stated he would not have issued a prescription of to Kim. In light of the evidence heard in this case I believe the current system of on-line prescription service needs to be reviewed. 2. It is of note, that the matter of concern regarding the ease in obtaining online prescriptions was previously raised by this court on 15th November 2019 in a Prevention of Future Death report following the tragic death of Deborah Headspeath on 3rd August 2017. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 In my opinion action should be taken in order to prevent future deaths, and I believe you or your organisation have the power to take any such action you identify. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely 28th March 2025 I, the Senior Coroner, may extend the period if I consider it reasonable to do so. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons;- 1. The other Interested Persons in this matter I am under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she believes may find it useful or of interest. You may make representations to me, the Senior Coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Dated: 31/01/2025 Nigel PARSLEY HM Senior Coroner for Suffolk Regulation 28 – After Inquest Document Template Updated 30/07/2021
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Minister of State for Health (Secondary Care) 39 Victoria Street London SW1H 0EU 08 April 2025 Our ref: HM Senior Coroner Nigel Parsley The Coroner’s Court and Offices Beacon House Whitehouse Road Ipswich IP1 5PB By email: Dear Mr Parsley, Thank you for your Regulation 28 report of 31st January 2025 sent to the Secretary of State about the death of Ms Kim Robinson. 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 Ms Robinson’s death and 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. Please accept my sincere apologies for the delay in responding to this matter. The key concern raised by both yourself and the online prescriber was that in consideration of this tragic case, the online prescription service needs to be reviewed. The online GP highlighted the following suggested changes: • There is a need for online prescribers to be able to access a patient’s records. These records could be attached to the consultation for review by the prescriber. • All patients could be asked for consent to share the details of their prescriptions with their current GP and/or regular practitioner. • Prescribers could have the ability to add comments when reviewing a consultation, whether it is approved or vetoed. • All consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” • Prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies. In preparing this response, my officials have made enquiries with the General Pharmaceutical Council (GPhC) to ensure we adequately address your concerns. The GPhC has provided a substantial response, which I will outline below, and I have also been advised that the organisation has contacted your office to obtain further details, in line with the GPhC’s policy to investigate any case where death of significant harm has been caused. I understand the concerns raised by both you and online prescriber regarding online prescribing practices. When used appropriately, online prescribing provides a valuable route for patients to access their prescription medicines which takes pressure off GP practices. Prescribers, whether working for the NHS or privately, in-person or remotely, are accountable for their prescribing decisions. They are expected to take account of appropriate national guidance. Prescribers should work with their patient and decide on the best course of treatment, with the provision of the most clinically appropriate care for the patient always being the primary consideration. In addition to the duty of the prescriber, patients themselves must be honest when providing information to an online prescriber so that they receive advice and medicines which are appropriate for them and so that risks can be managed. As has been highlighted in this very sad case, prescribers need full information to be able to prescribe safely. Where relevant, the General Pharmaceutical Council (GPhC) and other professional regulators, Care Quality Commission (CQC) and the Medicines and Healthcare products Regulatory Agency (MHRA) have the powers to investigate and take action against prescribers, products and suppliers who do not comply with legislation and national guidance. As previously mentioned, I approached the GPhC who advised that at the date of death, 12th May 2024, their March 2022 ‘Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet’ was in place - (a copy of which I have included with my response). Whilst propranolol was not referred to as an example in this guidance, ‘the GPhC considers it to fit within the category of requiring additional safeguards. Relevant to the concern you raise regarding access to patient records, and patient consent to share the details of their prescriptions with their current GP or regular practitioner, the March 2022 guidance sets out the precautions to put in place if medicines requiring additional safeguards are to be supplied online. These include but are not limited to assuring that the person has provided the contact details of their regular prescriber, such as their GP, and their consent to contact them about the prescription; and that the prescriber will proactively share all relevant information about the prescription with other health professionals involved in the care of the person (for example their GP). The guidance states that for medicines which are liable to abuse, overuse or misuse, or when there is a risk of addiction and ongoing monitoring is important, the prescriber should contact the person’s regular prescriber, who should confirm that the prescription is appropriate for the person and that appropriate monitoring is in place. If there are circumstances where the person does not have a regular prescriber such as a GP, or if there is no consent to share information, the prescriber must then decide whether or not to prescribe. They will need to think about the person’s best interests and make a risk-based assessment about whether they can prescribe safely, taking into account whether the person would be at risk of death or serious harm if they were also getting medicines from other sources. The prescriber must make a clear record setting out their justification for prescribing, or not prescribing. In your report you suggest that all consultations could include the question: “Have you ever had suicidal behaviour or thoughts?” On this point, the GPhC expects pharmacies to carry out a risk assessment for every part of the service they provide. If an appropriate organisation stated that this question should be included, then the GPhC would monitor this through its inspection processes. Relevant to your concern that ‘prescriptions could be also for smaller quantities, taking into account the possible lethal dose of the medicine. If necessary, dispensing should be limited to weekly or reduced frequencies’. The responsibility for prescribing rests with the prescriber who has clinical responsibility for that particular aspect of a patient’s care. Issuing shorter prescriptions could give the prescriber the opportunity to review the patient’s medicines, which is important for some groups of patients and may therefore be particularly appropriate in some cases. The service provider, whether NHS commissioner or private sector provider has a responsibility to ensure that adequate controls are in place, and they may also issue advice to prescribers about the length of time for which prescriptions should be issued. Further to the above, the GPhC has advised that they have recently updated their distance selling guidance (i.e. March 2022 guidance referenced above) in February 2025. The updated guidance can be found here: Guidance for registered pharmacies providing pharmacy services at a distance, including on the internet. The guidance was updated in response to concerns relating to unsafe prescribing and supply of medicines online and includes strengthened safeguards designed to prevent people from receiving medicines that are not clinically appropriate for them and may cause them harm. Specifically, the February 2025 guidance sets out what to include in a risk assessment when prescribing services are involved, this includes considering how the diverse needs of people using pharmacy services are identified, and how staff get users’ valid consent (for example, how staff assess the mental capacity of users). The February 2025 guidance states that “The risk assessment should cover the whole service, including the medicines and treatments which are provided”. This guidance updates on medicines that should not be supplied without further safeguards. This includes medicines which have a higher risk of fatality or serious harm if taken in overdose, and amitriptyline, propranolol, colchicine and carbamazepine are pulled out as examples. The GPhC have also indicated that they would consider propranolol to fall under the ‘medicines liable to misuse’ and ‘medicines and long-term conditions that require ongoing monitoring or management’ categories in their updated guidance. The February 2025 guidance sets out strengthened safeguards that should be in in place before supplying these types of medicines online. It states that a prescriber should not base prescribing decisions on the information provided in a questionnaire alone. Instead, the prescriber should independently verify the information the person provides, and get the information they need to support their prescribing decisions. This could be through timely two way communication with the person, accessing the person’s clinical records, or contacting the person’s GP, their regular prescriber, or a third-party provider. If the prescriber chooses not to use two-way communication with the person to support their prescribing decision, they should make a record, specific to the individual person's circumstances, justifying their reasons. If the prescriber cannot independently verify the information the person provides or get the information they need, the person should be directed to an appropriate care provider so that they can be appropriately assessed. Examples include, but are not limited to, an out-of-hours service, a local walk-in centre, or urgent care. for pharmacist It is unclear if the prescriber was a pharmacist, however the GPhC also has practise guidance here: https://assets.pharmacyregulation.org/files/2024-01/in-practice-guidance-for- pharmacistprescribers-february-2020.pdf. You may also want to contact the Care Quality Commission (CQC) and the General Medical Council (GMC) for information on the work they are doing to ensure online prescribing is safe. prescribers which found can be Lastly, I would like to assure you that we are committed to tackling suicide as one the biggest killers in this country. As part of this, the 8,500 new mental health workers we will recruit will be trained to support people at risk to reduce the lives lost to suicide. We are also committed to continuing to deliver the cross-sector Suicide Prevention Strategy for England published in 2023. This identifies a number of groups for tailored or targeted action at a national level, including people who have self-harmed and people in contact with mental health services. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, MINISTER OF STATE FOR HEALTH
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