Multiple emails sent by a pharmacy “to seek authorisation” for a patient’s anti-psychotic medication were ignored by a GP practice before he died by suicide, an inquest report published this week (July 29) found.
Assistant coroner for East Sussex Laura Bradford found that Thomas Joseph Geraghty, aged 39, “had been prescribed anti-psychotic medication since 2007, which he took on a daily basis”.
“His symptoms responded well to the medication and…Geraghty informed his family that he felt safe taking his medication and had intended to remain on it for life,” Bradford added.
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But “in January 2021, Geraghty’s GP surgery noted that he had moved out of its catchment area” and advised him “to register with a new surgery closer to his new home address”, the coroner’s report said.
The report added that Geraghty did “not appear” to do this.
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He instead “continued to receive a repeat prescription for his anti-psychotic medication”, as well as receiving his COVID vaccinations and smoking cessation advice texts from the surgery up to November that year, it said.
Bradford found that in May 2022, the surgery sent Geraghty a text message saying that it was “still prescribing his medication and that he needed to provide his new surgery details” – but “no details were provided”.
“Went without” medication
The coroner said that Geraghty was issued his last prescription, a two-month supply of anti-psychotic medication, in November 2022.
He requested a repeat prescription “via his usual automated service” in January 2023 but four days later appeared to have been “deregistered as a patient by the surgery”, she found.
“There does not appear to have been any communication with Geraghty at this time to inform him of the deregistration,” she added.
Read more: Man found dead after pharmacy worker raised alarm over missed methadone
She found that his pharmacy sent “two chaser emails” to the surgery “to seek authorisation for the prescription”.
“But no response was received,” she said, meaning Geraghty “went without his anti-psychotic medication”.
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“On the morning of June 28 2023, Geraghty entered the sea from the beach” and at around 11:45 that day, his body “was seen floating by a nearby lifeguard” but resuscitation attempts were unsuccessful, the report said.
The conclusion of the inquest was death by “suicide”, with his family noting that “some of his psychotic symptoms had returned in June 2023”.
“Particular concern”
In the report sent to Geraghty’s GP surgery, the coroner said that she had “a concern that individuals can be removed from the surgery as patients without any scrutiny as to whether the individual may be receiving vital medication”.
“There does not appear to be any process of review in relation to these patients to ensure that they will continue to receive their medication after they are deregistered from the surgery,” she added.
“This is of particular concern where a patient is deregistered and the surgery has not been provided with details of an individual’s new GP,” she said.
Read more: Coroner: Give pharmacies ‘obligation’ to report failure to collect methadone
“There is a concern that in these circumstances, an individual may be left without access to medication, which could cause or contribute to their death,” she added.
Last month, coroner Sarah Huntbach raised concerns about GP practice “safety measures” after advice from a dispensing pharmacist and consultant psychiatrist was ignored.
Huntbach found that the clinicians’ advice to change 55-year-old Debra Bates’ weekly prescription to a “four-day and three-day” prescription was not carried out by her GP pharmacist before she overdosed.
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