“During the Inquest evidence was heard that:- i”

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1. During the Inquest evidence was heard that:- i. On the 15" July 2016 a Consultant prescribed Edoxaban 60mg per day for long term anticoagulation treatment to be collected by the deceased on a weekly basis by repeat prescription issued by the General Practitioner and the Consultant sent a letter to the General Practitioner to confirm that plan of treatment. The repeat prescription for Edoxaban was not put on the deceased’s repeat prescriptions by the General! Practitioner and the deceased did not receive Edoxaban for administration after the 22™ July 2016 and he would not have had a supply of Edoxaban following his self-discharge from the Hospital on the 10" November 2016. The General Practitioner gave evidence that the Surgery had undertaken a “Significant Event Analysis” as to how the Edoxaban prescription had been missed and the _ investigation resulted in the following recommendations within the Surgery to prevent a recurrence:- 2. a. GP to review “active problems” on the computer system when any patient comes in, in order to ensure patient is on the appropriate treatment. b. In respect of discharge letters directing new medication ~ the letter will be sent on a task to a prescription clerk, who will add the new medication and issue a month's supply. If necessary (depending on | the type of medication involved) the task will include sending a Tequest to the patient to see the GP for review in a month's time. However, the General Practitioner confirmed that the above recommendations had not been included in any formal documented protocol and I was not satisfied that there was to be a note on a patient's record to alert a Doctor to a new medication subject to repeat prescription, bearing in mind that the deceased had seen a General Practitioner on the 13” September 2016, the 30" September 2016 and the 14 October 2016 without the omission being checked. li, The evidence at the Inquest revealed that the Wrightington, Wigan and Leigh NHS Foundation Trust does not have a protocol with regard to patients who self-discharge from the Hospital, particularly where they may be receiving necessary medication in the form of anticoagulation treatment. At the Inquest the deceased was identified as a vulnerable patient and the absence of a protocol is even more important in relation to a vulnerable patient. There is no protocol to contact the Police, General Practitioner, Family or Social Services to bring it to their attention that a patient has self- discharged so that they become aware and they can make contact with the patient following his discharge to ensure that he has appropriate support and necessary medication. I request the Senior Partner of the Grasmere Surgery, Leigh Health Centre, The Avenue, Leigh, to conduct a review of the documented protocols and systems relating to the recording of repeat prescriptions, particularly where repeat prescriptions are requested by a Consultant or a Health Professional outside the Surgery. The review should consider the training of Health Professionals, including Doctors, and check systems to ensure that any request for repeat prescription is recorded and within the knowledge of a Doctor treating a patient. The review should also consider an alert, either in the Notes or on the computerised system, to any Doctor or Nurse Practitioner to check medications, particularly new repeat prescriptions at the next appointment. I request the Chief Executive of the Wrightington, Wigan and Leigh NHS Foundation Trust conduct a review of policies, protocols and systems when a patient, particularly a vulnerable patient, self-discharges from the Hospital without necessary medications so that all Health Professionals, including Doctors, can be aware of the protocols if a patient self-discharges from the Hospital in circumstances similar to the deceased. ACTION SHOULD BE TAKEN In my opinion urgent action should be taken to prevent future deaths and I believe that you have the power to take such action.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2017-0225

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0