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A coroner has raised concerns over software used for ordering repeat medication, warning that it “gives rise to the risk that a patient will not be provided with the medication they need”.
In a ‘Prevention of future deaths’ report (PFD), issued to software provider Optum (formerly EMIS) on 10 November 2025, Alexander Frodsham, assistant coroner for Cheshire, expressed concern that its system removes patients’ medication from their list of repeat prescription after 12 months if a patient does not reorder it, without alerting their GP of this change.
The coroner raised these concerns after patient Alan Mitchell, aged 88 years, who had been advised to take proton pump inhibitors (PPIs) to manage Barrett’s Oesphagus since 2011, died following a heart attack on 12 March 2025.
In the PFD, the coroner noted that the patient stopped ordering his repeat prescription of PPIs in 2020. During a routine medication review in 2021, Mitchell told his GP that he was not experiencing symptoms, which required him to take more than one tablet per month, it said.
The coroner wrote: “At inquest, evidence was heard that, if a prescription is not re-ordered for a period of 12 months, that medication is removed by the EMIS software and no longer appears on the list of repeat prescriptions; further, that the general practitioner is not notified of this fact and is not prompted to authorise the change.
“Therefore, the GP is required to re-prescribe the medication which the system has removed, and this was done twice in Mr. Mitchell’s case.”
The patient was admitted to Macclesfield District General Hospital with an upper gastro-intestinal bleed on 8 March 2025, the coroner added.
“Although a gastroscopy was planned, this was not performed as there was no evidence of active bleeding and Mr. Mitchell’s underlying cardiac condition placed him at risk of a cardiac event during the procedure,” the coroner said.
On 12 March 2025, the patient complained of chest pain, with an ECG revealing that he had a heart attack, according to the PFD. It also said that the patient then became unresponsive and died a short time later.
The coroner wrote that while the removal of the patient’s repeat prescription from the EMIS system did not play a part in his death, “the alteration to a lifelong prescription without notification (nor any choice being given to) the GP gives rise to the risk that a patient will not be provided with the medication they need”.
“That risk is heightened when patients are elderly and/or prescribed multiple medications and/or when, as here, they do not re-order as they possess medication in reserve,” he said.
Optum was approached by The Pharmaceutical Journal but declined to comment.
The company must respond to the coroner’s report within 56 days from the date of publication and detail actions they have taken or propose to take.
