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An assistant coroner has given the Royal Pharmaceutical Society until August 6 to set out what steps it will take to address concerns that patients are being put at risk because its repeat prescribing toolkit fails to clear up pharmacists’ confusion over when they should dispense prescriptions.

During an inquest into the death of 56-year-old Simon Hockenhull, who died of natural causes at his home in December last year having been unable to control his diabetes, the assistant coroner for Cheshire Elizabeth Wheeler said some pharmacists interpreted a 28-day supply as a month, making it difficult for patients to get a further prescription in the same calendar month.

“I have heard that some diabetic medications and devices have a life span of 14 days. When two are prescribed, they therefore amount to a 28-day supply,” she said.

A 'month’ is being inconsistently defined

“At 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.”

The inquest heard Hockenhull, who was diagnosed with diabetes in 2017, died at his home on December 5, 2024 after suffering gastro-intestinal issues.

He had been unable to control his diabetes sufficiently since his diagnosis and that led to gastro-intestinal issues which the inquest heard “made him more prone to contracting infections and more vulnerable when he did contract them”.

Last year, the inquest was told, he was admitted to intensive care multiple times as a result of diabetic ketoacidosis after his “diabetic control significantly worsened”.

On December 5, Hockenhull was found collapsed at home but still breathing and although his brother called the emergency services, he died when paramedics arrived.

“Mr Hockenhull died as a result of contracting lobar pneumonia, contributed to by his underlying diabetes and diabetic gastro enteropathy which materially reduced his resilience,” Wheeler said in her report into the inquest.

Laying out her concerns, she said patients who have “a complex relationship with their medication and monitoring regime” are at risk of not taking their medication “as consistently as they need to”.

“For patients with a diagnosis of diabetes, this can have rapid and significant impacts on their health, including developing the life-threatening condition of diabetic ketoacidosis,” she said.

Wheeler said the toolkit, which was also developed by the Royal College of General Practitioners, “does not seem to address” the confusion which can lead to inconsistent dispensing and warned “prescribers and dispensers are unaware of this issue”.

Her report was also sent to Hockenhull’s family and Countess of Chester Hospital NHS Foundation Trust.