Recipient

Midway Pharmacy

First report 31 Dec 2024•Latest report 31 Dec 2024

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 1

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Midway Pharmacy linked to the concerns in each report. Select any concern, action or position to view the source wording.

31 Dec2024
West Yorkshire Eastern
Concerns raised5
1. Failure to obtain and supply prescribed anti-epileptic medication promptly
2. Lack of clear designated systems for dealing with medication supply shortages
3. Failure to provide leaflets explaining roles during medication supply shortages
1. Failure to learn lessons from potentially dangerous medication supply intervals
2. Failure of pharmacies to search for supplies when prescribed medication is unavailable
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 2
1. Position
  The pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.
  Disputes the concern
1. Position
  National medication shortages prevented the pharmacy from obtaining the prescribed Tegretol medication and require a national resolution.
  Unable to act
AI-generated summary

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.

Read the report on judiciary.uk
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
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
Page 2 · response
Published 9 January 2025
Open published response
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
Page 2 · response
Published 9 January 2025
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised5

Failure to obtain and supply prescribed anti-epileptic medication promptly

Lack of clear designated systems for dealing with medication supply shortages

Failure to provide leaflets explaining roles during medication supply shortages

Failure to learn lessons from potentially dangerous medication supply intervals

Failure of pharmacies to search for supplies when prescribed medication is unavailable

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Respondent positions 2