Man died after pharmacy left meds 'IOU' - coroner

A man died after his pharmacy ran out of epilepsy medication and he was instead left with an "IOU" note for the drugs, a coroner has said.

David Crompton fell and suffered a fatal heart attack on 13 December after Midway Pharmacy in Pudsey, Leeds, was unable to supply him with "essential" drug Tegretol, according to a report by West Yorkshire's senior coroner.

Kevin McLoughlin said in his Prevention of Future Deaths report that Mr Crompton, 44, had suffered a previous fall in 2024 after the same pharmacy ran out of the drug for over a week.

The coroner said pharmacists should have "clear designated systems" to deal with such shortages. Midway Pharmacy has been approached by the BBC for comment.

According to Mr McLoughlin's report, while the pharmacy had delivered other items of medicine to Mr Crompton's home address in December, a manuscript "IOU" had been left for Tegretol.

Without the medication, Mr Crompton's epileptic condition was likely to "destabilise and give rise to fits", the coroner said.

The 44-year-old's fall in December, which led to his death, followed another in April after Midway Pharmacy had failed to supply him with Tegretol for 10 days, Mr McLoughlin added.

In his report he said it was a "matter of concern" that for "relatively lengthy periods of time" Mr Crompton was without his medication and it was left to his family members to find an alternative pharmacy.

The coroner also wrote that at times of shortage, pharmacists should provide information directing patients to relevant hospital departments.

"It is important that when anti-epileptic medication is prescribed by a GP that this is obtained and supplied promptly by the dispensing pharmacy," he wrote.

"The inquest was informed that following the April 2024 episode, hospital specialists commented 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."

In his report, Mr McLoughlin also found that as well as epilepsy and a cardiac arrest, a lack of oxygen to the brain and a cervical spine injury had contributed to Mr Crompton's death.

Clare Pelham, CEO of the Epilepsy Society, has called for an urgent review into the medicine supply chain following Mr Crompton's death.

"For many people with epilepsy, there is no Plan B when their medication is not available and they cannot safely switch between different versions of a drug", she said.

It was "literally a life-threatening problem", Ms Pelham added.

"It is critical that another family doesn't have to experience this devastating loss."

The BBC has also approached the General Pharmaceutical Council for comment.

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