RPS asked for clarification on dispensing timelines following death of patient with diabetes

A coroner has written to the Royal Pharmaceutical Society (RPS) seeking clarification over prescribing and dispensing timelines following the death of a patient with poorly controlled diabetes.

In a ‘Prevention of future deaths’ (PFD) report, issued to the RPS and the Royal College of GPs (RCGPs) on 19 June 2025, Elizabeth Wheeler, assistant coroner for Cheshire, asked for clarity on whether pharmacists and GPs consider a 28-day supply of medicines as a calendar month following the death of Simon Hockenhull.

According to the PFD report, Hockenhull had been diagnosed with diabetes in 2017 and struggled to control it, leading to gastrointestinal issues, which made him more vulnerable to infections.

In 2024, Hockenhull was admitted to intensive care on multiple occasions owing to diabetic ketoacidosis, the report added.

The report said that on 5 December 2024, he died as a result of lobar pneumonia — contributed to by underlying diabetes and diabetic gastro enteropathy “which materially reduced his resilience”.

In her report, Wheeler said that during the inquest, she was informed that some diabetic medications and devices have a lifespan of 14 days, which means that when two of these items are prescribed, they amount to a 28-day supply.

There is a concern that some pharmacists interpret a 28-day supply as a month, which can “therefore be challenging to obtain a further prescription within the same calendar month”, it said.

The report said that some patients, may have a “complex relationship with their medication and monitoring regime”, adding that “the challenges this causes can mean that they then do not take their medication as consistently as they need to”.

In the case of patients with diabetes, this could have “rapid and significant impacts” on health, including the development of diabetic ketoacidosis, it revealed.

The report added: “The heart of the issue seems to be that a ‘month’ is being inconsistently defined. Sometimes it means 28 days, sometimes it is a calendar month.”

A repeat prescribing toolkit, developed by the RCGPs and the RPS “does not seem to address this issue”, meaning that prescribers and dispensers may be unaware of it, the report said.

The toolkit, which was commissioned by NHS England, was published in October 2024.

In England, 77% of prescriptions dispensed annually are repeats.

The toolkit is not intended as a clinical or prescribing guideline but is designed to help streamline repeat prescribing systems and help GP practices and primary care networks — together with community pharmacies and patients — to evaluate processes and identify areas for safety and efficiency improvements. 

The RPS said it would be responding to the coroner directly, with the coroner asking for a response by 6 August 2025.