Lack of medication reviews in primary care contribute to patient deaths – thematic review of prevention of future deaths reports 2019-2023
Authors: Thomson C , Ross L , Davies J 
Published: November 2024

Abstract

Introduction
With over 1 billion items dispensed in primary care each year, practices need robust systems to review repeat prescriptions and safeguard patients.1
The Care Quality Commission have reviewed areas of harm in relation to medicines.2 In general practice, errors in monitoring and review of repeat prescriptions create potential for harm and in some circumstances, death.
When reviewing medicines-related patient deaths, coroners may write prevention of future deaths reports (PFDs) to highlight matters of concern to a person or organisation who may have power to act.3

Aim
This retrospective case series aims to review coroners’ PFD reports over a 5-year period, with a focus on medicines-related deaths. The review will identify key themes, the most commonly prescribed medicines and any relevant patient demographics. Changes will be suggested to practice for any areas of concern or trends identified.

Methods
PFDs published on the judiciary website between 1st January 2019 and 31st December 2023 which reported on medication-related deaths were screened.3 Those relating to repeat prescribing were selected for analysis.
Inductive thematic analysis was used to assess PFDs and identify where failures in repeat prescribing processes contributed to medication-related deaths. The “Matters for Concern” were reviewed by three research collaborators, who independently coded the data and identified the key themes.
Following the initial screening process, demographic data (if known), relevant coroner notes, and available information on the drug(s) which contributed to patient deaths were extracted from the PFDs and recorded in a data table in Microsoft Excel.
Ethical approval was not required as the research used publicly available information.

Results
24 of 4781 PFDs related to repeat prescribing. The majority reported were female patients (67%, p&lt;0.05) with average age of 48. Although the geographic distribution of PFDs was varied, a substantial proportion were published in Greater Manchester (9/24 38%).
76% of named medications were opioid analgesics, mentioned significantly more than any others (p&lt;0.05). One third of the included PFDs described polypharmacy or repeat prescriptions taken alongside acute or over-the-counter medications.
57 matters of concern were raised by coroners, from which three key themes were identified: errors or discrepancies at the point of a transfer of care; the ability to obtain repeat prescriptions from multiple medication sources and a lack of robust medication review. Absence of medication review occurred most frequently (15/24 reports, 63%).

Discussion
This study identified where risks lie in repeat prescribing processes, with lack of robust medication reviews being most commonly linked to patient deaths. Inherently high-risk medicines, opioid analgesics, were most commonly described and should be prioritised for review. The average age was 48, suggesting older age may not be a risk factor in itself, but the contribution of polypharmacy was emphasised in the reports.
The sample size was small and the time to extract the information from the reports impacted on the length of the study period chosen. However, pharmacy teams in general practice have an essential role to play in supporting medication reviews. Development of guidance to support repeat prescribing will also help to better safeguard patients receiving repeat medication.

References
1. NHS Business Services Authority. Prescription Cost Analysis – England – 2022-23 [Internet]. 2023 [updated 2023 Jul 27; cited 2023 Jun 7]. Available from: https://www.nhsbsa.nhs.uk/statistical-collections/prescription-cost-analysis-england/prescription-cost-analysis-england-2022-23
2. Care Quality Commission. Medicines in Health and Social Care [Internet]. 2019 [updated 2019 Jun 28; cited 2023 Jun 7]. Available from: https://www.cqc.org.uk/publications/major-report/medicines-health-social-care
3. Judiciary UK. Reports to Prevent Future Deaths [Internet]. [cited 2023 Jun 7]. Available from: https://www.judiciary.uk/courts-and-tribunals/coroners-courts/reports-to-prevent-future-deaths/