Repeat prescriptions allow patients with long-term health conditions to obtain essential medication without arranging a new appointment every time. Used properly, the system is safe, practical and convenient.
The risk arises when repeat prescribing becomes automatic. A medicine may continue for months or years even though the patient’s health has changed, the original reason for treatment no longer exists or other medicines have been added.
A computer may generate the prescription, but a suitably qualified healthcare professional remains responsible for ensuring that the treatment is safe and appropriate.
If a failure to review repeat medication causes avoidable injury, the patient may be able to pursue a repeat prescription negligence claim.
Why do medicines need to be reviewed?
A medicine that was appropriate when first prescribed may not remain suitable indefinitely.
Over time:
- the patient may become frail;
- body weight may change;
- kidney or liver function may deteriorate;
- the underlying condition may improve or disappear;
- a safer treatment may become available;
- another clinician may prescribe an interacting medicine;
- the patient may begin experiencing side effects; or
- the risks of continuing treatment may outweigh the benefits.
A medication review allows the clinician and patient to consider why each medicine is being taken and whether it remains necessary.
The review should not begin with an assumption that every medicine must be stopped. For many patients, continued treatment is essential. The purpose is to reach a safe, informed and individual decision.
Our comprehensive guide to medication error claims explains the wider responsibilities of doctors, pharmacists, hospitals and care providers.
What do the GMC prescribing standards require?
The General Medical Council’s guidance on repeat prescribing states that doctors must ensure any repeat prescription they propose or sign is safe and appropriate.
The guidance says the doctor should agree with the patient how their condition will be managed, including a date for review. Systems should ensure:
- the correct patient receives the correct prescription;
- the correct dosage is prescribed;
- medicine usage and its effects are monitored;
- only competent staff prepare prescriptions for authorisation; and
- patients requiring further assessment are reviewed by an appropriate professional.
This means that responsibility is not removed merely because the prescription was prepared electronically or placed before the doctor for authorisation.
What is overprescribing?
Overprescribing does not simply mean that a patient is taking several medicines. A person with multiple conditions may require numerous appropriate treatments.
The Government’s national overprescribing review examined how unnecessary prescribing can be reduced while maintaining safe and effective care. It considered repeat prescribing, communication, transfers of care, alternatives to medication and the role of better medication reviews.
Problems may arise where:
- a medicine no longer has a clinical purpose;
- treatment continues for longer than recommended;
- a patient receives a higher dosage than necessary;
- the combined risks of several medicines are not considered;
- a medicine is used to treat the side effect of another drug;
- alternatives to medication are not considered; or
- the patient does not understand why the treatment is continuing.
Overprescribing may develop gradually. No single decision appears obviously dangerous, but the patient’s medication list expands while the opportunities to reconsider it are missed.
What is polypharmacy?
Polypharmacy commonly refers to a patient taking five or more medicines. The number is a warning indicator rather than proof of inappropriate treatment.
A major University of Liverpool-led Nature Health study examined 5.8 billion medicines dispensed to 52.6 million people in England. It found that approximately 15% of people had received five or more concurrent medicines by age 50, rising to 42% by age 70.
Separate University of Liverpool and Bangor University research examined adverse drug reactions among hospital admissions. Patients who experienced an adverse reaction were taking an average of 10.5 medicines, compared with 7.8 among other patients.
These figures do not mean that every patient taking several medicines is at risk or has received negligent care. They demonstrate why the combined treatment should be reviewed rather than each prescription being considered in isolation.
Who should be considered for a structured medication review?
The NHS England structured medication review guidance identifies several priority groups, including:
- people taking ten or more medicines;
- patients with severe frailty;
- care-home residents;
- people who have experienced recent falls;
- patients recently admitted to hospital;
- people taking medicines frequently associated with errors; and
- patients using potentially addictive pain medication.
A structured review should involve the patient in deciding whether the benefits of each medicine continue to justify the risks.
The absence of a review does not automatically establish negligence. A claim requires evidence that a review should reasonably have taken place and that competent review would probably have changed the treatment and prevented the injury.
What should happen during a medication review?
A proper review may consider:
- why each medicine was prescribed;
- whether the original condition still requires treatment;
- whether the medicine is working;
- whether the patient is taking it as intended;
- whether side effects have developed;
- whether the dosage remains appropriate;
- whether blood tests or other monitoring are up to date;
- whether kidney or liver function has changed;
- whether medicines are interacting;
- whether treatment is being duplicated;
- whether the patient is taking non-prescription products; and
- whether any medicine can safely be reduced or discontinued.
A review should also consider the patient’s own priorities. A theoretical long-term benefit may need to be balanced against immediate dizziness, falls, confusion or loss of independence.
Stopping medication can carry its own risks. “Deprescribing” should therefore be planned and supervised rather than undertaken suddenly by the patient or family.
What warning signs should prompt a review?
A review may be particularly important where a patient develops:
- unexplained dizziness;
- repeated falls;
- fainting or collapse;
- unusually low blood pressure;
- excessive drowsiness;
- new confusion;
- difficulty walking;
- poor appetite or substantial weight loss;
- kidney or liver problems;
- abnormal bleeding;
- irregular heartbeat;
- breathing difficulties; or
- repeated hospital admissions.
These symptoms can have many causes. The clinician should nevertheless consider whether medication is responsible, especially after a new drug or dosage change.
Can a prescribing cascade amount to negligence?
A prescribing cascade develops when a side effect is mistaken for a separate illness and another medicine is added to treat it.
For example, a patient may develop swelling, dizziness, confusion or stomach problems following treatment. If the relationship with the existing medicine is overlooked, a second prescription may be issued instead of reconsidering the original drug.
The new medicine may create further side effects or interact with the patient’s existing treatment.
A prescribing cascade is not necessarily negligent. The legal question is whether a reasonably competent clinician should have recognised the likely side effect and reviewed the original treatment.
Who is responsible for repeat prescriptions?
The clinician authorising a repeat prescription retains responsibility for ensuring that it is appropriate.
Depending on the circumstances, responsibility may also involve:
- the GP practice;
- a hospital consultant;
- an independent prescriber;
- a clinical pharmacist;
- a mental health service;
- a pain-management service;
- a private clinic; or
- an online prescribing provider.
Shared-care arrangements can make responsibility more complicated. One clinician may initiate the treatment while another issues the repeat prescription and carries out monitoring.
The GMC guidance on shared care emphasises the need for clear allocation of responsibility and effective communication.
A patient should not fall into a gap where each provider assumes somebody else is reviewing the medication.
Can a pharmacist be responsible?
Community and clinical pharmacists increasingly contribute to medication reviews. A pharmacist may identify unnecessary duplication, interactions, unusual dosages or medicines that require further monitoring.
However, the pharmacist is not automatically responsible for the prescriber’s decision to continue treatment. Liability depends on the pharmacist’s role, the information available and whether a serious concern should reasonably have been identified and communicated.
Where both the prescribing and pharmacy services were involved, each role may require separate expert assessment.
What injuries can result from inadequate medication reviews?
Potential consequences include:
- a medication-related fall;
- fracture or head injury;
- internal bleeding;
- kidney or liver failure;
- respiratory depression;
- abnormal heart rhythm;
- stroke;
- severe confusion or delirium;
- loss of mobility;
- avoidable hospital admission;
- worsening of an underlying condition; or
- death.
A claim should distinguish the injury caused by the medication from the patient’s pre-existing health problems. Independent expert evidence will normally be required.
What must be proved in an overprescribing claim?
The claimant must normally establish:
- The medication should reasonably have been reviewed, reduced, changed or stopped.
- The failure to do so fell below an acceptable professional standard.
- A competent review would probably have changed the treatment.
- The change would probably have prevented or reduced the injury.
The fact that another doctor later discontinued a medicine does not, by itself, prove that the earlier care was negligent. The earlier decision must be judged according to the patient’s condition and the information available at that time.
What evidence will be important?
Relevant evidence may include:
- the complete GP record;
- repeat-prescription histories;
- medication review records;
- hospital and specialist correspondence;
- blood-test results;
- kidney and liver function results;
- pharmacy dispensing records;
- hospital discharge summaries;
- care-home medication records;
- records of reported side effects;
- details of falls or hospital admissions; and
- statements from relatives and carers.
A clear chronology can reveal when a medicine was started, how long it continued, when the patient’s health changed and whether warning signs were overlooked.
What compensation can be recovered?
Compensation may cover:
- pain, suffering and loss of amenity;
- injuries caused by falls;
- additional hospital treatment;
- rehabilitation;
- care and assistance;
- mobility equipment;
- home adaptations;
- loss of earnings;
- medical and travel expenses; and
- future care or treatment.
If overprescribing contributed to a death, the estate and qualifying dependants may be able to bring a fatal clinical negligence claim.
How long do I have to claim?
The usual time limit is three years from the negligent treatment or the date the patient first had sufficient knowledge that the injury might be connected with negligence, if later.
Different rules apply to children and may apply where the patient lacks litigation capacity.
An NHS complaint or internal investigation does not stop the limitation period. Early legal advice is important, particularly where the prescribing history extends over several years.
Specialist pharmacist input
Overprescribing claims can require detailed consideration of numerous medicines, changing dosages, monitoring requirements and interactions.
Our legal team now includes specialist pharmacy knowledge. This helps us understand complex medication records, identify potential prescribing and monitoring failures and determine the expert evidence required to investigate a claim properly.
Speak to our medication negligence solicitors
If you or a family member has been injured because repeat medication was not reviewed, dangerous side effects were overlooked or unnecessary treatment continued, you may be entitled to compensation.
Our medication error claims specialists can investigate the complete prescribing history and advise whether the evidence supports a claim.
For free initial advice, contact Hutcheon Law or telephone 0151 724 7121.
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For Further Readings:
Wrong Dosage Medication Claims and Dangerous Drug Interactions
Dangerous Medication Combinations and Prescription Errors
Medication Error Claims: Can You Sue a Doctor or Pharmacist?
