Tramadol overdose death raises questions over repeat prescriptions

 

Geoffrey Sullivan, a senior coroner in Hertfordshire has written to the Chief Executive of NHS England Simon Stevens to express concern after the death of Mr Peter Cole.

 

On August 14th 2019 Mr Cole was found by his neighbour collapsed at home. Despite attempts by the emergency services to resuscitate him he, unfortunately, passed away later that day.

 

The causes of death listed on the post mortem were drug overdose and also ischaemic heart disease. The conclusion of the subsequent inquest was that Mr Cole’s death was prescription drug-related.

 

Mr Cole suffered from dementia and it was noted that he was regularly in receipt of multiple repeat prescription medicines. One of the medicines that he was receiving regularly was tramadol. He received 100 tramadol capsules per month.

 

This was the drug that Mr Cole overdosed on.

 

Mr Sullivan did not find probable contribution to Mr Cole’s death from the other medicines that were found to be in excess in his house.

 

An experienced mental health nurse gave evidence to the coroner and she indicated that this level of excess repeat prescription medication was not unusual. She said that she would often find large quantities of repeat prescription medicines and medical devices and that the control of supply was not always properly supervised. These patients would invariably have a level of mental impairment. She said that she would on occasion find ‘cupboards full’ of prescription medicines in peoples’ houses.

 

Mr Sullivan judged that there was a risk of future deaths and raised several issues as a matter of concern.

 

He indicated that repeat prescription medicines are not well enough monitored or supervised and therefore many people who are older or mentally ill may accumulate dangerous levels of these medicines.

 

He also asserted that the inadequate supervision of repeat prescribed medication was so widespread that the resultant waste of resources had a detrimental effect on the delivery of healthcare.

 

Mr Sullivan wrote to Simon Stevens to express his concern due to the risk of future deaths.

 

You can read the full coroner’s report here. 

 

At Pharmacy in Practice, we would like to hear about your own experience.

 

 

 

Poll indicates public support for community pharmacy

 

National polling carried out by the National Pharmacy Association has indicated strong public support for a greater role for pharmacies within the NHS post COVID19. The new research shows:

 

  • 74% want to see locally-based pharmacies better integrated with other services, operating as neighbourhood health and well-being centres and providing face-to-face advice
  • Only 11% support large scale automation of pharmacy services, with centralised dispensing and pharmacists working predominantly from GP practices or remotely
  • Pharmacists currently enjoy huge public support, with 81% of the public holding a favourable view of the sector – close to level of doctors and nurses (89%), and up 15% from 2016
  • 55% of the public have visited a pharmacy during the COVID19 crisis to collect prescriptions, buy medicines or seek medical advice
  • 89% of people believe pharmacies are playing an essential role in the COVID19 crisis
  • The vast majority of respondents (77%) say it is important to have face-to-face contact with their pharmacist

 

A nationally representative survey of n=1,000 respondents was conducted in the UK with 18+ year old members of the general public

 

Commenting on the findings, Chair of the National Pharmacy Association, Andrew Lane said:

 

“With many doctors surgeries closed during the pandemic, pharmacies have been on the NHS frontline during COVID19, working long hours and providing a vital service to communities up and down the country. This research shows not only the huge public support for pharmacists to play a greater role in the future of the NHS but also a strong attachment to neighbourhood services and the human touch in healthcare.”

 

Jackie Doyle-Price MP, a former Health Minister, said:

 

This research shows that the public value their face-to-face relationship with their local pharmacist, and that they have played a vital role by staying open during the COVID19 crisis when many health services have closed. The number of pharmacies and their closeness to local communities means they could play a much bigger role in tackling the NHS backlog, taking pressure off doctors and hospitals, and supporting public health.”

 

Lee Williams, pharmacist and owner of the Prescription Service Pharmacy in Knutsford, Cheshire, said:

 

“The research chimes very much with what my patients say to me – that they value what we do and they’d like to see us do even more to relieve pressure on the NHS.  It’s been a hard slog during the coronavirus pandemic, but it’s worth it to see our patients safe and well.  But to continue our vital services requires investment, especially if we want to help the NHS clear the backlog of care that’s built up over the past few months.”

 

Commenting on the ongoing negotiations, Andrew Lane, said

 

“The government continues to drag its feet over offering proper financial assistance for the sector. There are many community pharmacies up and down the country on the financial brink, crippled by the extra cost of COVID-19. If they close, the towns and villages they serve will lose a popular and life-saving asset.

 

“Similarly, if the government is serious about stopping the slow death of the high street it needs to act now and put its money where its mouth is. The government managed to find more than a billion pounds for the arts sector yet is dithering over financial aid to frontline health workers. The £370 million COVID crisis loans to pharmacists must be turned into a grant before it is too late. I call on the government to end the confusion around the loans and act now to save our pharmacies.”

 

Glasgow COVID-19 ‘mega lab’ opens

 

A new UK Government-funded Glasgow lab has begun processing COVID-19 test samples.

 

Funded by the UK Government, the Lighthouse Laboratory in Glasgow is part of what will be the biggest network of diagnostic testing facilities in British history, alongside other Lighthouse Lab sites in Milton Keynes and Alderley Park. All have been opened in recent days.

 

The newly operational lab will test samples from the regional centres where NHS staff and frontline workers with suspected COVID-19 infections are tested. It is hoped the lab will quickly move towards processing several thousand tests per day, before scaling up further to tens of thousands of tests per day.

 

The Glasgow facility will be staffed on a 24/7 basis by around 100 staff members. More than 800 volunteers came forward to help with the facility, including highly experiences molecular scientists, technicians and bioinformaticians – all with the relevant skills and experience to carry out COVID-19 testing.

 

Scottish Secretary Alister Jack said:

 

“The UK Government has committed to expanding our testing capacity across the UK. The completion of our network with the Lighthouse Lab in Glasgow is a tremendous achievement for all the partners in such challenging circumstances and only five weeks after this project was started.

 

“Scotland has world-class universities and I am pleased they have been involved in this UK-wide effort as we work together to protect the NHS and save lives. Dr Jodie Hay, a Chronic Lymphocytic Leukaemia researcher at the University of Glasgow, is one of the volunteers at The Lighthouse Lab in Glasgow. A cancer scientist with experience of working with patient samples and molecular lab techniques, Dr Hay volunteered so she could use her skills to help with COVID-19 response in the UK.”

 

Professor Dame Anna Dominiczak, University of Glasgow Vice-Principal and Head of the College of Medical, Veterinary and Life Sciences, who leads the team said:

 

“I am pleased that after weeks of hard work and continued effort by all involved, the University of Glasgow can now deliver the country new, large-scale testing facility, in conjunction with our industry partners and the NHS.

 

“I remain incredibly grateful to all partners and colleagues who have volunteered their time, expertise and skills for this testing facility. As a result of their willingness to help, we have equipped, staffed and set-up a new testing facility that is now operational and will be vitally important in the NHS efforts against this coronavirus pandemic. It has been said all over the world and confirmed by the WHO that we have to test, test and test more to fight the virus that has killed so many.”

 

Dr Hay said:

 

“I was one of the first volunteers selected to begin working in the Lighthouse Lab in Glasgow and it has been incredible to see how quickly everyone has been able to get this lab up and running so that we can begin processing the testing samples.

 

“Like my other colleagues working in the lab, we volunteered so that we could use the skills and expertise we have from our usual lab work in this response against COVID-19. Although these are challenging times, it feels positive to be able to use my skills and experience in this way and to be able to help.”

 

 

This circular is being shared under the Open Government Copyright licence.

 

 

Rugby player banned after prednisolone dispensed in error

 

Irish professional rugby player James Cronin has admitted to ‘entirely unintentional’ anti-doping offences after as part of an investigation by the European Professional Club Rugby (EPCR). Cronin took a number of doses of Prednesol 5mg (prednisolone) after having received it due to a dispensing error at his local pharmacy.

 

According to the investigation Cronin had been prescribed amoxicillin. This prescription had been emailed to the pharmacy where it was to be dispensed. The team doctor had indicated to Cronin that he had prescribed antibiotics but did not inform him of which antibiotic that he had prescribed. He did say that he had prescribed ‘antibiotics only’.

 

When Cronin went to collect the medicine at the pharmacy he was actually dispensed two medications, Germentin and Prednesol 5mg. Unfortunately, the Prednesol 5mg had actually been intended for another patient of the pharmacy but Cronin received it by mistake. The name ‘James Cronin’ name was on the medication labels.

 

Cronin followed the instructions on the medication labels and took 25mg of the Prednesol the day before the doping test and a further 20mg of Prednesol on the morning of the doping test.

 

He tested positive later that day for the banned substance prednisolone. After mitigation was considered Cronin avoided the standard two-year ban for intentional use of this type of banned substance and instead received a one month ban.

 

Whilst the investigation recognised that the error was not entirely his fault they did say that it was appropriate that he carries some responsibility for what had happened.

 

In a statement issued by the EPCR they said the following:

 

“Prior to the match against Racing 92, Cronin had been unwell and had been prescribed antibiotics, however, the pharmacy dispensed medication to him which was intended for another customer.

 

“On 23 November 2019, Cronin tested positive for prednisolone and prednisone which are banned substances under Section 9 of the 2019 WADA Prohibited List. Cronin had no Therapeutic Use Exemption permitting the use of prednisolone and prednisone.

 

“The Judicial Officer accepted evidence that the banned substances in the player’s sample were due to a dispensing error by the pharmacy and that the anti-doping violation was entirely unintentional.

 

“An independent Judicial Officer has decided that Cronin, who plays his club rugby for Munster in the Republic of Ireland, will be ineligible for a period of one month due to an unintentional anti-doping violation.

 

“Cronin co-operated fully with a subsequent investigation of the case by EPCR, and the matter was referred for decision to an independent Judicial Officer, Antony Davies (England).

 

“Although the Judicial Officer found that there was no significant fault on behalf of the player and that there were clear and compelling mitigating factors, he determined that the player had to bear some responsibility for what was in his sample.

 

Cronin has the opportunity to appeal the decision.

 

You can read the full determination by clicking here.

 

 

 

No recognition of sacrifices made by community pharmacy in England

 

In Scotland yesterday, the Scottish Cabinet Secretary for Health and Social Care Minister Jeane Freeman MSP acknowledged her support of the community pharmacy network by investing £5.5 million in the community pharmacy network.

 

She said:

 

This interim sum would cover the costs of equipment, adaptations to premises, additional staffing and locum cover when they have sickness absence.’

 

“All this was only an interim arrangement as she also pledged to meet in full, the additional costs faced by community pharmacy to support the NHS at this time.

 

“She also acknowledged the extensive role of community pharmacy as a central part of the primary care workforce, recognising that it is now the location where most people will secure the health care and support that they need. She said it was an ‘incredible and invaluable service’ and thanked the sector for its work.

 

The Scottish Cabinet Secretary also reminded the public that they needed to recognise the work of community pharmacies as part of the wider NHS and have patience when waiting in queues for help. This follows reports by PDA members across the country of abuse and violence towards pharmacy staff by angry and frustrated patients.

 

PDA Chairman Mark Koziol said;

 

“For front line pharmacists in Scotland, this will be an incredibly moving announcement that genuinely recognises the challenges they face and values their support. It will allow owners to put additional staffing in place such as a second pharmacist and recognises the additional costs in coping with COVID-19. This is a real boost for pharmacists, their teams and for their employers”.

 

In England, the community pharmacy network is trying to respond to the same extra-ordinary pressures as in Scotland, but on a much larger scale. It is trying to do so against a background of £100s of millions of reductions in funding imposed by the government in recent times.

 

From member feedback, the PDA has revealed that pharmacists want to cover additional shift patterns, they want to work alongside second pharmacists and with more staff to assist, they want to split their teams to improve resilience and give them at least the hope of an occasional rest break, but they are unable to do so as their employers just cannot afford the costs. In a large proportion of pharmacies, it is unsurprising that so many staff are falling ill as they have not even been provided with Personal Protective Equipment.

 

PDA Chairman Mark Koziol stated;

 

“Pharmacists working in England will be dismayed that NHS England attributes so little value to their incredibly hard work.

 

“Last week, whilst the Minister of Health persuaded the Chancellor to write off £13.4 billion of central NHS debt, he offered community pharmacists only a loan, the size of which does not even cover the cost of the additional drugs bill.

 

“In this war against the Coronavirus in England the community pharmacy troops are being asked to join the front line, without ammunition, without helmets, without rations and without re-enforcements; it is a travesty, that NHS England attributes so little value to the incredibly hard work being delivered by pharmacists and their teams.

 

“This cannot be allowed to continue any longer and we demand that NHS England provides at least the same support to the pharmacy front line teams as has the NHS in Scotland.”

 

The PDA calls on Matt Hancock and NHS England to match the level of support provided to community pharmacists in Scotland or he must explain why pharmacists in English pharmacies are not worthy of such support.

 

Visit the PDA website here.

 

 

 

Pharmacists asked to break the law during COVID-19 outbreak

 

The pharmacist Defence Association (PDA) has said this week that ‘large numbers’ of PDA members are reporting they are being asked to break the law by their employers under the pre-text of the COVID-19 pandemic.

 

These situations have included being offered a locum placement, but only on the condition that the pharmacist is prepared to sign on remotely to allow the pharmacy to operate in their absence.

 

Other examples involve where unqualified staff would be assembling and supplying prescription medicines in the absence of a pharmacist or where an employer is asking the responsible pharmacist to sign on simultaneously for more than one pharmacy.

 

The PDA has said that they are extremely concerned that some employers are inciting pharmacists to break the law through internal guidance and using the pandemic as an excuse. They have concerns that in their view it is apparent that some pharmacy multiples wish to operate pharmacies without a pharmacist even though a locum would be available, but the pharmacy is unprepared to use them.

 

In an article on their website the PDA brought members’ attention to the recent GPhC and PSNI joint statement two weeks ago, the pharmacy regulators recognised that in the highly challenging circumstances of the pandemic, pharmacists may need to depart from established procedures in order to care for patients and their families.

 

The PDA supported this move by the regulators as it enables pharmacists to put patients’ needs ahead of the rules and the regulations at a time of crisis. They said it is important to note that the GPhC has subsequently confirmed that this measure is only capable of being activated by the Responsible Pharmacist (RP) as it is they who are on the front line and must make this individual professional decision based upon local circumstances, quality of the available staff and the availability of another pharmacist via phone or video link.

 

The PDA has vigorously stated that this facility has been provided by the regulators for Responsible Pharmacists should it be required by them and strictly for the period of the COVID-19 outbreak only.

 

The PDA has said there is a ‘free for all’ attitude to the interpretation and implementation of the above directive and they have said that they are aware of employers who have threatened to discipline employees who are unwilling to follow unlawful company diktats. The PDA has also stated that locums have been blacklisted after raising concerns about chaotic pharmacies and unlawful working practices to the superintendent.

 

Speaking to PIP, Director at the PDA Paul Day commented:

 

“It’s unacceptable for employers to break the law or encourage their employees to do so. The responsible pharmacist regulations are about safety, and in these unprecedented conditions with all parts of the system under pressure, it could not be more critical that safety is maintained for patients, that standards be maintained and that public confidence in the sector is strengthened.”

 

The PDA has been publishing regular updates throughout the COVID-19 outbreak which you can access here.