The General Pharmaceutical Council (GPhC) has opened an investigation into concerns raised around the death of a man who was unable to obtain his epilepsy medication from a pharmacy.
It was ruled earlier this year that David Crompton died aged 44 following a fall in December 2024 that was made more likely by the absence of his epilepsy medication Tegretol (carbamazepine). He had instead been given an ‘IOU’ by the pharmacy for the missing medication.
A Prevention of Future Deaths Report in January had called on the pharmacy involved and the pharmacy regulator to take action following the incident.
The GPhC has now provided its response to the report, confirming that an investigation was open into the individual pharmacy professional involved and ‘into the concerns raised’ by the coroner.
Its correspondence said: ‘It is important that when anti-epileptic medication is prescribed by a GP that this is obtained and supplied promptly by the dispensing pharmacy.
‘It is a matter of concern that for relatively lengthy periods on two occasions Mr Crompton was left without this important medication.’
In addition to the incident in December, Mr Crompton had previously experienced a fall in April 2024 when his pharmacy was unable to supply the medication for 10 days, during a time of fluctuating supply nationally.
The GPhC added: ‘We are aware of supply issues with some Tegretol products.
‘While we do not have a direct role in the manufacturing of medicines or wider issues such as supply and shortages, we understand that medicines shortages can cause problems for patients and carers.
‘We know that pharmacy professionals are also concerned and have to use their professional judgement and make decisions in challenging situations, balancing a range of factors such as individual patient needs and available supplies of medicines.’
It added: ‘Our standards require pharmacy professionals to deliver patient-centred care, which includes making the care of the patient their first concern and using their judgement to make professional decisions. This may include making decisions about providing medication in an emergency.’
The regulator confirmed that the pharmacy involved had been inspected by its inspection team and that evidence suggested the pharmacy ‘has robust processes in place to manage out-of-stock medicines, including for Tegretol’.
‘The inspection included looking for evidence about the systems in place to manage medicines which were out of stock at the pharmacy and where there were supply issues at the wholesalers,’ it said.
‘This was to ensure practices in the pharmacy relating to stock management were appropriate.’
While the full inspection report would soon be published, the GPhC said: ‘Evidence collected during the inspection shows that the pharmacy has robust processes in place to manage out-of-stock medicines, including for Tegretol.
‘The pharmacy uses electronic ordering, with a twice daily check by team members. Patients can receive a text message to inform them when their medicines are available.
‘The pharmacy obtained its medication from recognised wholesalers and all team members across the company accessed a communication platform for queries such as checking stock availability.’
Charities and MPs have said Mr Crompton’s death had added urgency to their calls for a government review into the issue.
One practice in Sheffield said they had been told not to start new patients on them which ‘felt like a step back to the dark ages’.
Other drugs shortages, including for pancreatic enzyme replacement therapies with some intermittent problems also reported for some ADHD medications.
A report from the Royal Pharmaceutical Society had warned that medicines shortages were increasing professional tensions between GPs and pharmacists.
It called for a national policy on medicines shortages and other structural and practical changes including enabling community pharmacists to amend prescriptions.
A survey of GPs in 2024 found that three quarters (74%) had experienced moral distress because they are unable to prescribe medicines patients need due to ongoing shortages.
A version of this article was first published by Pulse’s sister title The Pharmacist
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There may be room to adjust pharmacy ordering and stock-holding levels to cope with government incompetence in ensuring adequate supply, but this does not excuse the system that does not allow pharmacies to obtain necessary medication when they ask for it.
Pharmacies could order adequate stocks for a 3-month in-shop stockholding, but this would not prevent all such problems :- what if a patient moves house – and the new pharmacy does not have any access to stock of their medicines which that pharmacy has not needed before then?
What if there is a change of prescription? pharmacy may not have any, and may be unable to get 3-months supply overnight!
What if consultant hands over prescribing to GP and local Pharmacy from Hospital pharmacy? Can the Chemist insist the Hospital give them the hospital supply? Obviously that would be the clinically responsible thing to do, but can you imagine any hospital doing that?
The problem is inadequate NHSE oversight of supply issues and lack of teeth to punish unconforming wholesalers and manufacturers!
It is also very unhelpful that we are relying on imports of overseas manufacture – when we could be making it ourselves in UK
This is an NHSE/DoH/Government problem : What is government going to do about it?
I believe other steps that could be considered to prevent such deaths in the future include:
The neurologist could prescribe alternative medication in such situations in each patient’s follow-up or discharge letters, which would be communicated to both the team and the patient. The patient is to hold such a letter in file to show the chemist.
If there is a problem with the brand of medication, a different brand could be considered for a short period, if appropriate.
The patient should be warned about the risks of running out of medication due to such issues and advised to visit the Accident and Emergency (A&E) department if necessary. should be warned against swimming and driving when he stops taking the medication.