A community pharmacy and the sector's regulator have been told to take action following the death of a man who was unable to obtain his epilepsy medication.

David Crompton, aged 44, died following a fall on 13 December 2024, made more likely by the absence of medication, the coroner suggested.

In December 2024, the pharmacy had delivered Mr Crompton's other medications but left an 'IOU' for epilepsy medication Tegretol (carbamazepine).

He 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.

At that time, hospital specialists said that the lack of Tegretol had 'likely contributed' to increased seizure activity.

But the coroner said it was 'questionable whether lessons were learned' from the incident in April.

'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,' senior coroner for West Yorkshire (Eastern) Kevin McLoughlin wrote in his report.

He noted that it has been left to the patient's family to contact other pharmacies to try and obtain the medication, rather than the pharmacy searching for supplies.

And he reported comments made at the inquest that 'the pharmaceutical profession should have clear designated systems to deal with any shortages of supply encountered; for example, reference to hospital departments to ensure patients are not left without medications'.

'Leaflets explaining the role of those concerned in this situation were not provided,' the coroner added.

Alison Fuller, director of health improvement and influencing at national charity Epilepsy Action, said the tragic event 'highlights the pressing need to fix the medication supply chain in our country'.

'Medication availability has been a fluctuating issue, with 2024 being a critical year. Concerningly, our helpline has started to receive enquiries from people unable to access Tegretol again in the new year, showing how unpredictable this matter can be,' she said.

'Last year, nearly 40% of people with epilepsy who had to skip or switch medication due to shortages had more seizures. Some people started having breakthrough seizures, after long periods seizure-free. This can’t happen again.

'It’s clear that medication shortages are a complex issue, and there are multiple factors at play. But patient safety needs to be front and centre to tackle this issue. It’s really concerning to hear there seemed to be a lack of clarity in processes to help Mr Crompton receive his medication if this wasn’t available in the first instance, as highlighted in the report.

'What is clear, is that he was left without vital medication, which can increase risks.'

Ms Fuller said Epilepsy Action had been working with other charities to 'call for an urgent review of the medication supply chain by the health secretary since last year'.

'People with epilepsy need swift action, now, or more lives could be at risk,' she added.

The General Pharmaceutical Council and the pharmacy have been approached for comment.