Simon Hockenhull

Ms Elizabeth WHEELER, 
Assistant Coroner for the coroner area of Cheshire 
Ref: 2025-0295 

By email via:  

30th July 2025  

 cc: 

Dear Ms Elizabeth Wheeler,  

RE: Regulation 28 Prevention of Future Deaths  (PFD) Report for Mr Simon 
Hockenhull, deceased. 

We are writing to you regarding the report into the death of Mr Simon Hockenhull 
dated 12th June 2025. We would like to express our sincere condolences to the 
family of Mr Hockenhull. 

The Royal Pharmaceutical Society (RPS) is the professional leadership body for 
pharmacists and pharmacy in Great Britain, representing all sectors of pharmacy. 
Our role is to lead and support development of the pharmacy profession including 
the advancement of science, practice, education and knowledge in pharmacy. We 
transferred our regulatory role to the General Pharmaceutical Council (‘GPhC’) in 
2010,  and  they  now  regulate  pharmacy  and  pharmacy  professionals  in  Great 
Britain. 

In considering our response, we have sought input from the RPS Expert Advisory 
Groups. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We acknowledge the conclusion from the inquest on 10th June 2025 that the death 
of Mr. Hockenhull was as a result of contracting lobar pneumonia, contributed to 
by  his  underlying  diabetes  and  diabetic  gastro  enteropathy  which  materially 
reduced his resilience. 

We also note the brief summary of matters of concern in the PFD Report:  

‘In  the  course  of  this  inquest,  I  have  heard  that  some  diabetic  medications  and 
devices  have  a  life  span  of  14  days.    When  two  are  prescribed,  they  therefore 
amount to a 28 day supply. 

I have heard  that  this  can  cause problems as  there are  some pharmacists  who 
interpret a 28-day supply as a “month”, and that it can therefore be challenging to 
obtain a further prescription within the same calendar month.  For patients who 
already have a complex relationship with their medication and monitoring regime, 
the challenges this causes can mean that they then do not take their medication 
as consistently as they need to. For patients with a diagnosis of diabetes, this can 
have rapid and significant impacts on their health, including developing the life-
threatening condition of diabetic ketoacidosis. 

At the heart of the issue seems to be that a “month” is being inconsistently defined. 
Sometimes it means 28 days, sometimes it is a calendar month. 

The RCGP RPS “Repeat Prescription Toolkit” (October 2024) does not seem to 
address this issue, so it may be that prescribers and dispensers are unaware of 
this issue.’ 

It is challenging to comment as fully as we would wish  as we are not in possession 
of the full details  of the case and there are still a number of  unknown elements 
from the Report (for example we do not yet know what  diabetic medication had 
been prescribed for the deceased, or if it was the case that the medication couldn’t 
be ordered?). We would like however to address your general concerns around 
the RCGP RPS Repeat Prescribing Toolkit and the issue of prescription duration. 

The  NHS  prescribes  and  dispenses  over  1  billion  items  per  year  and  the  vast 
majority  of  patients  in  England  receive  their  medicines  safely  and  on  time. 
However, in 2021, the Department of Health and Social Care published its report 
into  overprescribing  -  Good  for  you,  good  for  us,  good  for  everybody:  a  plan  to 
reduce overprescribing to make patient care better and safer, support the NHS, 

 
 
 
 
 
 
 
 
 
 and  reduce  carbon  emissions.  This  made  20  cross-sector  recommendations  to 
address  the  concerns  around  over  prescribing  of  medicines  that  may  not  be 
appropriate.  One  of  the  recommendations  was  to  develop  a  repeat  prescribing 
toolkit.  

The RCGP RPS Repeat Prescribing Toolkit was commissioned by NHS England 
to  help  practices  improve  the  consistency  of  repeat  prescribing  processes  and 
support this with training resource.  

At  the  time  of  drafting  the  RCGP  RPS  Repeat  Prescribing  Toolkit,  the  Toolkit 
working  group  (made  up  of  practicing  GPs,  Clinical  Pharmacists,  Patients,  GP 
practice staff, NHS England policy leads and regulators), had been informed that 
NHS England may be exploring work on prescription duration and so it was agreed 
that  specific  guidance  on  prescription  duration  was  out  of  scope  for  the  toolkit. 
The toolkit was never intended to be a clinical guideline and so would not have 
addressed the specific issues that you have highlighted in this case. Annex A of 
the  Toolkit  (page  87)  details  what  was  within  and  outside  of  the  scope  of  the 
Repeat Prescribing Toolkit.  

You are correct, in highlighting that there is a variation between the understanding 
of a length of a ‘month’.  

Most  medications  are  prescribed  as  (calculations  of)  28-day  supplies  (e.g.  28 
days/56  days/84  days).  This  often  aligns  with  the  standard  pack  sizes  of  the 
majority  of  medications.  This  allows  quantities  of  different  medications  to  be 
synchronised so that a patient prescribed multiple medications should be able to 
order once per supply and receive an equal amount of all medications to manage 
their  medications.  To  avoid  any  gaps  in  medication  provision,  prescribers  will 
often need to issue 13 x 28-day prescriptions over the course of the year. 

Patients are usually advised to order their prescription medications 7-14 days in 
advance of running out, depending on the GP practice and community pharmacy 
workload. So,  a  patient's  request  for  medication  within  14  days  of  the  due  date 
would usually be accepted and issued despite being an 'early' request, as it allows 
the  community  pharmacy  time  to  order  and  dispense  the  medications,  then  the 
patient to collect the medication before their dose is due. Most GP practices set 
deadlines  for  medication  requests  to  be  processed  by  their  prescribers  (an 
example of this may be within a 48-hour period), and then community pharmacies 
usually mirror this. This should allow medication to be available at the pharmacy 
for  the  patient  to  collect  before  their  dose  is  due.  Some  practices  /  pharmacies 
may ask for a longer lead time depending on their workload. 

 
 
 
 
 
 
 
 
 
 Whilst it is a risk that patients may forget to order their medication or order late or 
or  there  is  a  delay  in  the  prescription  being  issued  from  the  GP  practice  or 
community pharmacy, it is not usually linked to the medication duration of 28 vs 
30  days. It  is  worth noting  that  legislation permits  the  community  pharmacist  to 
issue an emergency supply of a patient’s regular medication following appropriate 
clinical checks.  

Calendar months in the year would be 28, 29 (leap year), 30 and 31 days, but this 
would  be  unworkable  as  previously  mentioned,  medication  pack  sizes  are 
determined  by  the  manufacturer  and  the  licensing  is  based  on  the  pack  size 
submitted.  Splitting  some  packs  means  the  pharmacy  would  be  supplying  ‘off 
label’  which  can  bring  separate  issues  around  that.  Again,  these  will  vary 
depending on whether they are a “calendar” pack or a standard pack. 

It is also worth noting that guidance on the supply of medication “Original  Pack 
Dispensing (OPD)” was published in 2023 following a public consultation, and the 
Human  Medicines  Regulations  2012  (HMRs)  were  amended  to  allow  Original 
Pack  Dispensing  (OPD).  The  integrity  of  medication  packaging  is  also  an 
important safety feature, and not all medication packs can and should be split.  

In  general,  clinicians  should  consider  the  individual  needs  of  each  patient  and 
their ability to manage their medication. Vulnerable patients and for those patients 
whose ability to self-manage their medication is an issue, should form part of any 
risk assessment, care plan and structured medication review. 

Thank you for highlighting your concerns in this prevention of future death report. 
We  will  raise  awareness  of  the  report  through  our  communications  and 
engagement with other key medicines and patient safety stakeholders who play 
an important role in providing advice and support to the profession. It would also 
help if you and the family of Mr. Hockenhull were happy to give permission for us 
to  see  the  full  details  of  the  case,  in  order  to  understand  the  details  of  what 
happened and if there is any further learning that could be shared with members 
of  both  the  Royal  Pharmaceutical  Society  and  Royal  College  of  General 
Practitioners.  

Kind regards  

Patient Safety Manager  
Royal Pharmaceutical Society