Alan MITCHELL · Prevention of Future Deaths report

On 18 March 2025 I commenced an investigation into the death of Alan MITCHELL aged 88. The investigation concluded at the end of the inquest on 03 November 2025. The conclusion of the inquest was that:

Natural causes

Alan Mitchell had a medical history which included Barrett’s Oesophagus. The condition had been diagnosed in 2011 with a recommendation for lifelong management with PPI medication and continued surveillance by way of periodic gastroscopies. In 2020 Mr. Mitchell stopped ordering the PPI medication on repeat prescription from his General Practitioner. 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. At a routine medication review in 2021, Mr. Mitchell told his GP that he was not experiencing symptoms which required him to take more than one tablet per month.

On 8th March 2025, Mr. Mitchell was admitted to Macclesfield District General Hospital, with evidence of an upper gastro-intestinal bleed. 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. On 12th March 2025, Mr. Mitchell complained of chest pain and was short of breath; an ECG revealed that he had suffered a heart attack. Mr. Mitchell became unresponsive and he died at the hospital a short time later.

(brief summary of matters of concern)

Although the removal by the software of Mr. Mitchell’s repeat prescription played no causative part in his sad 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.