David Crompton, a 44-year-old epilepsy patient, tragically died following a fall attributed to the unavailability of his prescribed medication, Tegretol. An inquest into his death revealed a series of failures by his local pharmacy, Midway Pharmacy in Pudsey, to ensure he received his crucial medication. On two separate occasions, the pharmacy was unable to provide Crompton with Tegretol, leaving him without the drug for extended periods. The first instance, in April 2024, resulted in a fall after approximately 10 days without medication. The second instance, in December 2024, proved fatal. The coroner highlighted the pharmacy’s practice of leaving an “IOU” note instead of providing the medication, a practice that directly contributed to the destabilization of Crompton’s epileptic condition and ultimately led to his fatal fall. The inquest also revealed that the burden of locating the medication fell on Crompton’s family, rather than the pharmacy actively seeking alternative sources. This systemic failure underscores a critical gap in the pharmaceutical supply chain and raises serious concerns about patient safety.
The coroner’s report emphasized the lack of clear protocols within the pharmaceutical profession for handling medication shortages. The absence of established systems for sourcing alternative supplies, particularly in cases involving critical medications like Tegretol, left Crompton vulnerable and ultimately contributed to his death. The coroner stressed the necessity for pharmacies to proactively engage with hospital departments or other pharmacies to ensure patients are not left without essential medication, a practice that was demonstrably absent in Crompton’s case. The lack of informative leaflets explaining the roles and responsibilities of those involved in medication shortages further exacerbated the situation, preventing Crompton and his family from understanding their options and advocating for his needs effectively.
The tragic case of David Crompton highlights the broader issue of medication shortages within the UK healthcare system. While a supply notification was issued in May 2024 regarding Tegretol liquid, the Department of Health and Social Care claimed to be unaware of any ongoing supply issues affecting other formulations of the drug at the time of the inquest. This raises questions about the effectiveness of communication and monitoring within the pharmaceutical supply chain, and the potential for similar incidents to occur. The coroner’s report underscores the urgent need for a comprehensive review of medication supply procedures to ensure patient safety and prevent future tragedies stemming from medication unavailability.
Clare Pelham, chief executive of the Epilepsy Society, voiced her concerns regarding the ongoing medication shortages and their potential consequences, calling for government action to address this critical issue. She stressed that medication shortages represent a life-threatening problem for individuals with epilepsy, many of whom cannot safely switch between different versions of their medication, even if the active ingredient is the same. Pelham emphasized the urgent need for a government review of the medicines supply chain and the prioritization of this issue by Health Secretary Wes Streeting. She poignantly questioned how such a preventable death could occur in the UK due to a medication shortage.
Further illustrating the devastating consequences of medication shortages, the inquest into the death of toddler Ava Hodgkinson earlier the same year provides another chilling example. Ava contracted strep A and experienced a fatal delay in receiving antibiotics due to a shortage at her local pharmacy. The pharmacist was unable to provide an alternative strength of the prescribed amoxicillin due to regulations requiring an amended prescription from the doctor, even though the same dosage could have been administered. This bureaucratic hurdle resulted in a delay that ultimately contributed to Ava’s death from “overwhelming sepsis.”
The coroner in Ava’s case issued a warning to the Department of Health and Social Care, urging action to prevent similar tragedies. He highlighted the “restrictions” that prevented the pharmacist from dispensing an alternative strength of the medication, despite having the same medication in stock, and called for a review of these regulations. The coroner stressed the need for a more flexible system that allows pharmacists to provide equivalent dosages of the same medication during shortages, emphasizing the potential risk of future deaths if such changes are not implemented. Both David Crompton’s and Ava Hodgkinson’s cases underscore the devastating impact of medication shortages and the urgent need for systemic change within the UK’s pharmaceutical supply chain. These tragedies highlight the critical importance of ensuring patients have reliable access to essential medications and the need for clear protocols to manage shortages effectively. The calls for government action and a comprehensive review of the system underscore the urgency of this issue and the need to prioritize patient safety above all else.
