31 Dec 2024 David Joseph Crompton · Prevention of Future Deaths report West Yorkshire Eastern
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Concerns raised 5 Failure to obtain and supply prescribed anti-epileptic medication promptly View source Lack of clear designated systems for dealing with medication supply shortages View source Failure to provide leaflets explaining roles during medication supply shortages View source Failure to learn lessons from potentially dangerous medication supply intervals View source Failure of pharmacies to search for supplies when prescribed medication is unavailable View source See 2 more concerns
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David Joseph Crompton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Joseph Crompton, who had epilepsy, was left without his prescribed Tegretol for approximately 10 days in April 2024 and again in December 2024. His falls in both periods occurred when he was without the medication, and the inquest recorded a fall downstairs on 13 December 2024, with causes of death including hypoxic ischaemic encephalopathy, out-of-hospital cardiac arrest and cervical spine injury. The principal concerns were delays in supplying essential anti-epileptic medication, reliance on family members to seek alternative supplies, and the absence of clear systems for managing medication shortages.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midway Pharmacy; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain and supply prescribed anti-epileptic medication promptly
Wider context from the report “(1) 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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midway Pharmacy; that does not assign responsibility.
PFD Monitor interpretation Lack of clear designated systems for dealing with medication supply shortages
Wider context from the report “(4) 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, reference to hospital departments to ensure patients are not left without important medications . Leaflets explaining the role of those concerned in this situation were not provided.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midway Pharmacy; that does not assign responsibility.
PFD Monitor interpretation Failure to provide leaflets explaining roles during medication supply shortages
Wider context from the report “(4) 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, reference to hospital departments to ensure patients are not left without important medications. Leaflets explaining the role of those concerned in this situation were not provided .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midway Pharmacy; that does not assign responsibility.
PFD Monitor interpretation Failure to learn lessons from potentially dangerous medication supply intervals
Wider context from the report “(3) 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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Midway Pharmacy; that does not assign responsibility.
PFD Monitor interpretation Failure of pharmacies to search for supplies when prescribed medication is unavailable
Wider context from the report “(2) 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 .
” Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.
Verbatim wording from the response “(2) 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.” Source location Response from Midway Pharmacy
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation National medication shortages prevented the pharmacy from obtaining the prescribed Tegretol medication and require a national resolution.
Verbatim wording from the response “The process of managing owings is staged to ensure we obtain patients’ medications in a prompt and timely manner. On this occasion, only a single supplier (AAH Pharmaceuticals) had the medication in stock, and other Midway pharmacies could not obtain supplies. There was a clinical risk of changing the brand of medication supplied due to the condition being treated, and Mr Crompton was referred to other pharmacies that may have had the medication in stock.” Source location Response from Midway Pharmacy
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations