A MAN suffered a fatal fall after his pharmacy reportedly left an ‘IOU’ for his prescribed medication – as they were unable to source it.
David Crompton, 44, died on December 13.
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He died due to injuries after a fall down the stairs which resulted in loss of oxygen to the brain and cardiac arrest, an inquest heard.
David’s epilepsy was a contributing factor, according to the report.
The Leeds resident had been prescribed Tegretol, among other medicines, to treat his condition.
But on two occasions he was left without the drug when Midway Pharmacy in Pudsey was unable to supply it.
The first time was in April 2024, when David was left without the medicine for around 10 days, which is when he experienced his first fall.
The second and fatal fall occurred in December after the pharmacy had “left a manuscript ‘IOU’ in relation to Tegretol at his home when other medicines were delivered,” said the coroner.
He added that David should not have been left to try and source the medicine from elsewhere – that was the responsibility of the pharmacy.
“Without his medication his epileptic condition was likely to destabilise and give rise to fits,” the coroner said.
He added it was a “matter of concern that for relatively lengthy periods on two occasions, Mr Crompton was left without this important medication”.
Clare Pelham, chief executive of the Epilepsy Society, said the tragic case shows shortages of epilepsy medications must be “at the top of Wes Streeting’s agenda”.
Writing for P3pharmacy, she said: “The Epilepsy Society, working with other charities and pharmacy organisations, has been calling for several months on the government to conduct an urgent review into the medicines supply chain that is resulting in repeated shortages of vital medications.
“Our hearts go out to David Crompton’s family and friends. How can it be the case that sadly someone dies as a result of a medicines shortage in the UK?
“We have been warning for months of the worst and most extreme outcome that medication shortages can have for people with epilepsy.”
The coroner said: “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.
“The inquest was informed that following the April 2024 episode, hospital specialists commented [to Mr Crompton] that the absence of Tegretol for around 10 days ‘will likely have contributed to your seizure activity’.
“It is questionable whether lessons were learnt from this potentially dangerous interval.
“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; for example, references to hospital departments to ensure patients are not left without important medications.
“Leaflets explaining the role of those concerned in these situations were not provided.”
Drug shortages taking lives
In May last year, the Department of Health and Social Care issued a supply notification in relation to Tegretol 100mg/5ml liquid.
Manufacturer Novartis announced in April some supplies were available but that “it may take some time for supply to return to normal levels”.
A spokesperson for the Department of Health and Social Care has said it’s not aware of any current supply issue affecting any formulation of Tegretol.
This is not a little administrative issue that can be left to junior officials in the Department of Health & Social Care.
Clare Pelham
Sun Health has contacted the General Pharmaceutical Council for comment.
Epilepsy is the most common serious neurological condition and affects more than half a million people in the UK – around one person in every hundred.
Ms Pelham said: “For many people with epilepsy there is no plan B when their medication is not available. They cannot safely switch between different versions of a drug, even if the active ingredient is the same.
“This is not a little administrative issue that can be left to junior officials in the Department of Health & Social Care.
“This is literally a life-threatening problem. And it needs to be at the top of Wes Streeting’s agenda.”
David’s case isn’t the only example of medication shortages that have led to people’s deaths.
Earlier this year an inquest was held into the death of toddler Ava Hodgkinson after she contracted strep A.
She experienced a delay in receiving antibiotics due to a shortage at the pharmacy and soon after died of “overwhelming sepsis” that was “likely” caused by strep A.
Concluding the inquest into Ava’s death on January 8, coroner Chris Long said he would write to Health Secretary Wes Streeting calling for pharmacists to be allowed to give medication in a “different denomination” during shortages.
He said there was a “risk” of future deaths unless such a change takes place.
Under current rules, pharmacists are only allowed to prescribe alternative medication if the Department of Health has issued a Serious Shortage Protocol notice.
Ava Hodgkinson ‘would have lived longer’ if antibiotics was given faster
AVA HODGKINSON would have lived longer if she’d been given antibiotics sooner, an inquest has heard.
A coronor has issued a warning to the government after a toddler died of ‘overwhelming sepsis’ because rules meant a pharmacist was not allowed to give her a different strength of the antibiotic she had been prescribed.
Coronor Christopher Long said that there was a “delay” in Ava receiving the right medication due to “restrictions” currently in place across the country.
A GP had prescribed the two year old amoxicillin at a strength of 250mg/5ml, the coroner said.
But when her family went to collect the medicine from the chemists, they were told that there was only a dose of 125mg/5ml left in stock.
The coroner said that Ava’s parents ‘could have’ been instructed to provide 10ml of the lower dosage but were not allowed to without an ‘amended prescription’ from the doctor, it was heard.
Ava sadly died and Mr Long, area coroner for Lancashire and Blackburn, has now issued a warning to the Department of Health and Social Care, stating that action should be taken to prevent future deaths.
An inquest into the youngster’s passing heard she was examined by a GP at lunchtime on December 13, 2022, after a “short illness” – but no infection was found.
It was reported that the doctor requested a prescription of amoxicillin – a penicillin antibiotic used to bacterial infections – at 1pm but this was not issued until 2.04pm.
But, when Ava’s family went to collect the medication, which was ordered in a dose of 250mg/5ml, they were told the pharmacy ‘did not have this strength in stock’.
The coroner commented that they did however have the antibiotic in a measurement of 125mg/5ml in stock – but “could not issue this”.
Mr Long said: “Restrictions currently in place prevent a pharmacist issuing any different strength of medication without an amended prescription, even where the medication can be provided to enable the same dose to be administered.”
The coroner said on this occasion, Ava’s parents “could have” been instructed to provide 10ml thus enabling the same dose of antibiotics to be provide.
“This led to a delay in Ava receiving antibiotics,” he added.
On December 14, the toddler was taken to Ormskirk District General Hospital in Lancashire where upon arrival she went into cardiac arrest and despite attempts to resuscitate, she did not recover.
The coroner said she died of ‘overwhelming sepsis’ resulting from a Group A Streptococcus infection.
In light of her passing, he has issued a warning to the government.
Mr Long said: “Evidence from the Department of Health and Social Care included that this issue was being actively considered but it was explained the issue was complex and any change was likely to need public consultation and ministerial support.
“It was also explained that it was not possible to provide any timeframe for any appropriate steps to be taken to consider changing the restrictions preventing pharmacists from issuing medication where they can provide the same dosage of the same medication in a different denomination.”
The organisation has 56 days to respond to his comments.
“In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action,” Mr Long said.
