PFD report

Dyllon Shaun Graham Milburn · Prevention of Future Deaths report

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Issued 21 May 2021•Manchester City

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
4

Of 3 recipients

Stated actions
4

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of patient alerts for requesting and collecting repeat prescriptions
    Part of recurring concern: Unreliable prescription collection and delivery arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    The EMIS Web functionality was working as designed and complied with NHS Digital’s specified system requirements.

    Stated by EMIS GroupDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of patient alerts for requesting and collecting repeat prescriptions

Wider context from the report

“The system for repeat prescriptions does not currently allow for alerts to be sent to a patient to remind them to request and collect their repeat prescription to encourage compliance. ”

Is this part of a recurring concern?

Yes — Unreliable prescription collection and delivery arrangements.

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The EMIS Web functionality was working as designed and complied with NHS Digital’s specified system requirements.

Verbatim wording from the response

“Firstly, we reviewed the functionality available within EMIS Web and confirmed that it was working as designed and in a manner that complies with the system requirements specified by NHS Digital.”

Source location

2021-0167-Response-from-EMIS_Published
Page 1 · response
Published 24 May 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Changes to the EMIS system cannot be influenced by NICE.

Verbatim wording from the response

“We have reflected on the circumstances surrounding Mr Milburn’s death, and the concerns raised in your report, in relation to NICE’s work. You suggest that an automated alert be added to the EMIS system to remind people to request and collect their repeat prescription to encourage compliance. While NICE is not able to influence changes to the EMIS system, the following NICE guidelines contain recommendations relevant to this report.”

Source location

2021-0167-Response-from-NICE_Published
Page 1 · response
Published 24 May 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

NICE considers no action required because its implementation tools are put into practice locally.

Verbatim wording from the response

“NICE produces tools to support implementation of our recommendations, but they are put into practice locally. Therefore, we do not consider that any action is required by NICE in response to your report.”

Source location

2021-0167-Response-from-NICE_Published
Page 1 · response
Published 24 May 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The practice lacks sufficient administrative and clinical resources to respond appropriately to alerts about missed repeat prescriptions.

Verbatim wording from the response

“There would also need to be a protocol in place to detail what an appropriate response would be when such an alert was triggered. Given that an alert would have to apply to all medications to all patients across the practice, there are concerns about the volume of alerts that may be triggered and that the practice does not have sufficient resources to provide an appropriate response to such alerts either in terms of administrative or clinician staffing or time.”

Source location

2021-0167-Response-from-GPs_Published
Page 2 · response
Published 24 May 2021

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.4

  1. 1

    Open a dialogue with the Royal Pharmaceutical Society to consider improving pharmacy and general-practice IT integration for prescription collection visibility.

    Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 24 May 2021.
  2. 2

    Review EMIS Web functionality to confirm it operates as designed and meets NHS Digital requirements.

    Stated by EMIS GroupStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.
  3. 3

    Consider developing digital tools to further support patient medication compliance.

    Stated by EMIS GroupStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
  4. 4

    Undertake an internal review focused on repeat medications and compliance.

    Stated by EMIS GroupStated completedThe respondent said that this action was complete when they made their response on 24 May 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Monthly pharmacy meetings to identify uncollected prescriptions are not feasible because patients use multiple pharmacies and pharmacy and GP IT systems are incompatible.

    Stated by Royal College of General PractitionersUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Open a dialogue with the Royal Pharmaceutical Society to consider improving pharmacy and general-practice IT integration for prescription collection visibility.

Verbatim wording from the response

“Given the above, I recommend that RCGP opens a dialogue with our colleagues at the Royal Pharmaceutical Society to consider this matter in more detail. As above, Medical Protection Society has made recommendations in the past and clearly the clinical question remains. However, since then, IT systems have become universal and the volume of prescriptions issued annually has markedly increased. The RCGP view is that much greater integration of pharmacy and GP IT systems will likely be needed, not least that any approach must be automated given the scale of prescribing across the country.”

Source location

2021-0167-Response-from-RCGP-Published
Page 2 · response
Published 24 May 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review EMIS Web functionality to confirm it operates as designed and meets NHS Digital requirements.

Verbatim wording from the response

“Firstly, we reviewed the functionality available within EMIS Web and confirmed that it was working as designed and in a manner that complies with the system requirements specified by NHS Digital.”

Source location

2021-0167-Response-from-EMIS_Published
Page 1 · response
Published 24 May 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Consider developing digital tools to further support patient medication compliance.

Verbatim wording from the response

“We are presently considering a number of potential digital tools that we could look to develop so as to aid further patient compliance.”

Source location

2021-0167-Response-from-EMIS_Published
Page 2 · response
Published 24 May 2021

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Undertake an internal review focused on repeat medications and compliance.

Verbatim wording from the response

“With regard to the Regulation 28 report dated 21 May 2021 (the “Report”), we were saddened to read of this incident. We treat such matters with the utmost seriousness and an internal review has been undertaken, focusing on the issue of repeat medications and compliance.”

Source location

2021-0167-Response-from-EMIS_Published
Page 1 · response
Published 24 May 2021

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Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Monthly pharmacy meetings to identify uncollected prescriptions are not feasible because patients use multiple pharmacies and pharmacy and GP IT systems are incompatible.

Verbatim wording from the response

“collected or not. In the past, one of the main medical defence organisations, The Medical Protection Society, did recommend a monthly meeting with the local pharmacy to ascertain what prescription had been issued and not collected; the focus was particularly on patients with psychosis such as schizophrenia. The underlying reasoning was that such individuals might be at higher risk of self-harm. However, soundings I have had with other senior colleagues is that none of currently do this, not least with the universal use of electronic prescribing, in many cases it would not be feasible as prescriptions are frequently sent to a large number of pharmacies. To compound matters, the IT systems that Pharmacies use are different to that in general practice.”

Source location

2021-0167-Response-from-RCGP-Published
Page 2 · response
Published 24 May 2021

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026