PFD report

David Joseph Crompton · Prevention of Future Deaths report

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Issued 31 Dec 2024•West Yorkshire Eastern

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
5

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
3

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to obtain and supply prescribed anti-epileptic medication promptly
    Part of recurring concern: Failure to provide required medication promptly when clinically needed
  2. Lack of clear designated systems for dealing with medication supply shortages
    Part of recurring concern: Unreliable access to clinically required medication during supply shortages
  3. Failure to provide leaflets explaining roles during medication supply shortages
    Part of recurring concern: Unreliable access to clinically required medication during supply shortages
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Action

    Publish guidance explaining how pharmacies should respond when prescribed medicines are unavailable.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.
  2. Action

    Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.

    Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    The pharmacy’s staged process sought medication supplies, and referral to other pharmacies followed unsuccessful attempts to obtain the prescribed brand.

    Stated by Midway PharmacyDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to provide required medication promptly when clinically needed.

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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. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable access to clinically required medication during supply shortages.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable access to clinically required medication during supply shortages.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Failure to reliably learn from medication incidents and implement safeguards.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable access to clinically required medication during supply shortages.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Publish guidance explaining how pharmacies should respond when prescribed medicines are unavailable.

Verbatim wording from the response

“In November 2024 we published an article about medicines shortage, https://www.pharmacyregulation.org/about-us/news-and-updates/regulate/struggle-around-medicines-shortages The article states that if the pharmacy is unable to supply a particular medicine stated on prescription then they should talk to the patient to discuss their options. The article outlines examples of steps that pharmacy should take.”

Source location

Response from General Pharmaceutical Council
Page 2 · response
Published 9 January 2025

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Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Inspect the pharmacy’s systems for managing out-of-stock medicines and supply issues.

Verbatim wording from the response

“The particular pharmacy has been inspected by our Inspection Team, who looked for evidence that the pharmacy was meeting our Standards for Registered Pharmacies. The purpose of these standards is to create and maintain the right environment in pharmacies to protect and improve people’s health and wellbeing. 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. This was to ensure practices in the pharmacy relating to stock management were appropriate.”

Source location

Response from General Pharmaceutical Council
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

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

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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
Page 2 · response
Published 9 January 2025

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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

Manufacturing medicines and wider supply and shortage issues fall outside the regulator’s direct role.

Verbatim wording from the response

“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. 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.”

Source location

Response from General Pharmaceutical Council
Page 2 · response
Published 9 January 2025

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Clarify SOP wording to require comprehensive records of patient-interaction outcomes.

    Stated by Midway PharmacyStated completedThe respondent said that this action was complete when they made their response on 9 January 2025.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Clarify SOP wording to require comprehensive records of patient-interaction outcomes.

Verbatim wording from the response

“Whilst all processes were followed as above, we identified a need for clearer wording on our SOP to ensure comprehensive notes are made on patient records detailing”

Source location

Response from Midway Pharmacy
Page 1 · response
Published 9 January 2025

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026