Student died after systemic failure to supply epilepsy drug

A coroner has said that a pharmacy “should have sought to find a solution” when it “could not” supply a student with life-saving medication.

Legal case in court
Superdrug: The locum pharmacist "involved in this case no longer works with us"

Charlie Marriage died of sudden unexpected death in epilepsy (SUDEP) “likely contributed to by his lack of medication despite his efforts to obtain it over the course of two days”, a coroner’s report this week (January 28) revealed.

Inner South London assistant coroner Xavier Mooyaart found that Marriage, who was a student at Brunel University, “had a longstanding diagnosis of idiopathic generalised epilepsy” but that his seizures “had become well managed with medication, in particular Fycompa (Perampanel)”.

Read more: Patient dies after pharmacy ‘unable to supply’ epilepsy meds for 10 days

On June 25 2021, Marriage was prevented from making the “long journey” to an Uxbridge pharmacy to pick up his repeat medication after being “notified to self-isolate for COVID-19”, the report said.

“He sought to obtain a new repeat prescription via his GP practice for a local pharmacy, but this was not recognised to be urgent in time” and both his GP practice and the university pharmacy were closed over the weekend, it added.

“Wasted calls”

On June 26, Marriage “called 111, which promptly arranged for a ‘referral’ for his medication to be sent to a local pharmacy”, the coroner found.

“There it was not promptly identified that the Fycompa could not be supplied, resulting in several wasted calls to 111 and the loss of time and motivation,” he added.

The pharmacist referred him back to 111 although “it was they that should have sought to find a solution”, the coroner said.

Read more: Pharmacist unable to prevent Costa allergy death due to EpiPen shortage

“111 identified that a clinician would be required to help resolve the situation, but Marriage did not receive a call back from one,” Mooyaart said.

“That night he suffered a seizure that caused his death at home,” he added.

“The lack of Fycompa likely increased the prospect of a severe seizure and contributed to his death,” he said.

“Cliff-edge conditions”

Mooyaart found that “the growing risk of [Marriage] suffering SUDEP over the 48 hours since his last dose had not been recognised or resulted in appropriate prioritisation, safety-netting or an emergency supply”.

He said that those with “cliff-edge conditions” like Marriage’s are not “identified within the health system” as being at “risk of a sudden crisis” without their medication and that the “urgency and level of danger is not quickly…understood” when patients seek medical advice.

The coroner raised concerns that sending medication-dependent patients to a pharmacy “may not reliably mitigate their risks quickly where it is unlikely the medication can be expected to be in stock”.

Read more: Coroner: Woman dies after buying off-label POMs online ‘over 100’ times

“It may not be identified that for some patients their medication is not likely easily available on an ad-hoc local basis,” he added.

Mooyaart also found that “generic safety-netting/worsening advice” leaves such patients “at significant risk without medical oversight”.

The coroner sent his report to NHS England (NHSE), the Waterloo Health Centre, Superdrug, the locum pharmacist employed in a particular Superdrug branch at the time, the London Ambulance Service, and Derbyshire Health United.

Locum “no longer works with us”

Superdrug yesterday (January 29) told C+D that its “thoughts and condolences are with Marriage’s family”.

“The independent locum pharmacist involved in this case no longer works with us,” it said.

“The safety and well-being of our patients remain our top priority – we take all necessary steps to ensure the highest standards of service are upheld at all times,” it added.

Read more: Coroner: Young man overdosed after receiving double script from P2U and Lloydspharmacy

An NHSE spokesperson expressed its “deepest sympathies” for Marriage’s loved ones, adding that it will “carefully consider the issues raised” and respond to the report “in due course”.

Out-of-hours GP service Derbyshire Health United told C+D that it too is “carefully reviewing the coroner’s findings and, as a commissioned service, will work closely with NHSE and other partners to address the recommendations”.

C+D also approached Marriage’s GP practice for comment.

“Left without important medications”

This month, another coroner found that a patient died after he was unable to obtain his epilepsy medication for 10 days.

The coroner called for pharmacists to refer patients to hospital departments to ensure they “are not left without important medications” during drug shortages.

Read more: Coroner: Patient overdoses after ‘excess’ bank holiday diazepam and codeine scripts

Meanwhile 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 Jacobs.

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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Kate Bowie

Read more by Kate Bowie

Kate Bowie joined C+D as a digital reporter in August 2023 after graduating from a master’s in journalism at City, University of London. She began covering the primary care beat at the end of 2022, when she carried out several health investigations focused on staffing issues, NHS funding and health inequalities.

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