Senior coroner for West Yorkshire Kevin McLoughlin has urged that pharmacists “have clear designated systems to deal with any shortages” after a man who was unable to obtain his epilepsy medication on several occasions died.
David Crompton, aged 44, “had epilepsy and was prescribed…the anti-epileptic medication Tegretol”, McLoughlin’s report published last week (January 9) said.
But in April 2024, he was “left without the medication for approximately 10 days as the pharmacy could not supply it”, it added.
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“In December 2024, he was again left without the Tegretol” and the pharmacy “left a manuscript ‘IOU’ in relation to Tegretol at his home when other medicines were delivered”, it said.
“Without his medication his epileptic condition was likely to destabilise and give rise to fits” – “his falls both in April and December 2024 occurred when he was left without his essential medication”, the report added.
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The inquest found that Crompton’s cause of death was hypoxic ischaemic encephalopathy, “out of hospital cardiac arrest”, “cervical spine injury secondary to fall” and epilepsy – all “resulting from a fall downstairs on December 13 2024”.
“The inquest was informed that following the April 2024 episode, hospital specialists commented that the absence of Tegretol for around 10 days ‘will likely have contributed to [Crompton’s] seizure activity’,” the coroner said.
“It is questionable whether lessons were learned from this potentially dangerous interval,” he added.
Obtain and supply “promptly”
McLoughlin raised concerns that “for relatively lengthy periods on two occasions Crompton was left without this important medication”.
“It is important that when anti-epileptic medication is prescribed by a GP that this is obtained and supplied promptly by the dispensing pharmacy,” he added.
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McLoughlin said that Crompton’s family members told the inquest that “when the pharmacy was unable to supply the prescribed Tegretol medication, it was left to them to contact other pharmacies to see if they could obtain it, rather than for the pharmacy to search for supplies”.
“Comment was made at the inquest to the effect that the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered,” he said.
This could include “reference to hospital departments to ensure patients are not left without important medications”, he added.
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McLoughlin sent the report to both the pharmacy and to the General Pharmaceutical Council (GPhC), adding that in his opinion “action should be taken to prevent future deaths”.
C+D approached the pharmacy for comment. The GPhC declined to comment but said it would respond formally in due course.
Shortage tragedy
In August, a coroner found that a “national shortage” of EpiPens meant that a pharmacist could not prevent the death of 13-year-old Hannah Eniola Angela Ayomipo Jacob.
Jacobs was “incorrectly” served a “dairy hot chocolate at Costa Coffee Barking despite her mother informing staff of a dairy allergy” on her way to a dentist appointment.
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But when Jacobs was rushed to a pharmacy, it “had only one paediatric injector that was of an insufficient dosage”, the report said.
Meanwhile, a coroner’s report last month found that a woman with fibromyalgia died from multiple organ failure with two medicines purchased from websites selling off-label prescription medications found in her body.
