Read: Streeting must act now to prevent another Tegretol shortage death

A patient with epilepsy suffered a fatal fall after his pharmacy reportedly left an ‘IOU’ for his prescribed Tegretol when it was unable to source the anti-epileptic drug, a coroner has said. 

In a report issued on New Year's Eve, West Yorkshire senior coroner Kevin McLoughlin said 44-year-old David Joseph Crompton of Leeds died last December 13 following a fall downstairs, with his injuries and resulting loss of oxygen to the brain and cardiac arrest listed as a primary cause of death. 

Mr Crompton’s epilepsy was also a contributing factor, the coroner found. He was prescribed Tegretol, among other medicines, and on two occasions was left without the drug when Midway Pharmacy in Pudsey was unable to supply it. 

The first instance was in April 2024, when Mr Crompton was left without the medicine for around 10 days, during which time he had a first fall. 

The second and fatal fall came 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. 

“Without his medication his epileptic condition was likely to destabilise and give rise to fits,” the coroner said, adding that it was a “matter of concern that for relatively lengthy periods on two occasions Mr Crompton was left without this important medication”.

The coroner 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.

“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.”

In May last year, the Department of Health and Social Care issued a supply notification for Tegretol 100mg/5ml liquid, with manufacturer Novartis announcing in April that some supplies were available but “it may take some time for supply to return to normal levels”. 

National media coverage from May last year suggests that some patients were also unable to get their prescribed Tegretol tablets. It is unclear from the coroner’s report which Tegretol formulation was prescribed to Mr Crompton. 

A spokesperson for the Department of Health and Social Care told P3pharmacy: “We are not aware of any current supply issue affecting any formulation of Tegretol.”

Midway Pharmacy has been approached for comment. The coroner’s report was sent to both the pharmacy and the General Pharmaceutical Council, with both parties under a duty to respond by February 27 outlining a proposed course of action or explaining why no action is proposed.

Writing for P3pharmacy, 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”.