A West Yorkshire senior coroner has warned that “future deaths will occur unless action is taken”, following an inquest into the death of a 44-year-old man, who received an ‘IOU’ for his epilepsy medication from a Leeds pharmacy last December.
David Joseph Crompton, who had epilepsy, died following a fall down the stairs on 13 December, senior coroner Kevin McLoughlin concluded.
In the inquest report, McLoughlin stated the cause of death to be hypoxic ischaemic encephalopathy (a form of brain damage caused by lack of oxygen), cardiac arrest, a spine injury due to the fall and epilepsy.
Earlier in December, Crompton had received a manuscript ‘IOU’ for his epilepsy medication, Tegretol (carbamazepine), when his other medicines arrived from Midway Pharmacy in Pudsey.
‘Questionable whether lessons were learnt’
He had previously been left without his medication in April 2024 for around 10 days, as the pharmacy could not supply it.
Tegretol shortages had been reported to Epilepsy Action around this time, with different Tegretol tablets from the manufacturer Novartis being in and out of stock over several months.
McLoughlin said in his coroner’s report: “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 inquest heard that hospital specialists had told Crompton in April that the 10-day gap in Tegretol supply “will likely have contributed to your seizure activity”. McLoughlin commented that it is “questionable whether lessons were learnt from this potentially dangerous interval”.
He added: “During the course of the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths will occur unless action is taken.”
McLoughlin stressed that it is important that anti-seizure medications are “supplied promptly by the dispensing pharmacy” when prescribed.
A comment was also made, saying that “the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered”.
McLoughlin added: “The evidence given by family members at the inquest was 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.”
‘Pressing need to fix the medication supply chain’
Alison Fuller, director of Health Improvement and Influencing at Epilepsy Action, said: “We are extremely saddened to hear about the passing of Mr Crompton. This tragic event highlights the pressing need to fix the medication supply chain in our country. Medication availability has been a fluctuating issue, with 2024 being a critical year. Concerningly, our helpline has started to receive enquiries from people unable to access Tegretol again in the new year, showing how unpredictable this matter can be.
“Last year, nearly 40% of people with epilepsy who had to skip or switch medication due to shortages had more seizures. Some people started having breakthrough seizures, after long periods seizure-free. This can’t happen again.
“It’s clear that medication shortages are a complex issue, and there are multiple factors at play. But patient safety needs to be front and centre to tackle this issue. It’s really concerning to hear there seemed to be a lack of clarity in processes to help Mr Crompton receive his medication if this wasn’t available in the first instance, as highlighted in the report.
“What is clear, is that he was left without vital medication, which can increase risks. We have been working in coalition with other charities to call for an urgent review of the medication supply chain by the Health Secretary since last year. People with epilepsy need swift action, now, or more lives could be at risk.”
In 2024, a report from the Nuffield Trust said medicine shortages reflect “significant problems in the global medicine market”. Alongside Tegretol, Lamictal (lamotrigine) was also consistently affected by the shortages.
McLoughlin called on Midway Pharmacy to take action to prevent future deaths, who have until 27 February to respond with proposed actions.
The inquest took place between 23rd and 31st of December, 2024.
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