David Crompton

Kevin McLoughlin 
Senior Coroner of West Yorkshire 

By email via: 

26 February 2025 

Dear Mr McLoughlin 

Re: Regulation 28 Report to Prevent Future Deaths: Mr David Joseph Crompton 

Thank you for sending us your Regulation 28 report regarding the death of Mr David Crompton. We are 
sorry to hear about this sad death and we would like to pass on our sincere condolences to Mr 
Crompton’s family. 

By way of background, the GPhC is the independent regulator for pharmacists, pharmacy technicians 
and pharmacies in Great Britain. Our main job is to protect, promote and maintain the health, safety 
and wellbeing of members of the public by upholding standards and public trust in pharmacy. This 
includes maintaining a register of pharmacy professionals and premises, setting regulatory standards 
and investigating concerns. 

We note that in the ‘Matters for Concern’ section of the regulation 28 report the Coroner has 
highlighted four concerns namely. 

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. 

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. 

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. 

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. 

pharmacyregulation.org | info@pharmacyregulation.org |020 3713 8000 

 
 
 
 
 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.  

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 the pharmacy should take. 

On receipt of the regulation 28 report, the circumstances surrounding the death and the Coroner’s 
concerns have been considered, together with how the GPhC needs to act to protect the safety of 
patients, uphold standards and maintain public trust in pharmacy.  

Inspection 

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.  

The Inspection report will be published in due course. Evidence collected during the inspection shows 
that the pharmacy has robust processes in place to manage out-of-stock medicines, including for 
Tegretol. The pharmacy uses electronic ordering, with a twice daily check by team members. Patients 
can receive a text message to inform them when their medicines are available. The pharmacy obtained 
its medication from recognised wholesalers and all team members across the company accessed a 
communication platform for queries such as checking stock availability.  

Action Taken by our Enforcement (Fitness to Practise) Team 

The GPhC Fitness to Practise team investigates concerns about individual pharmacy professionals where 
there may be a risk to patient safety and/or where public confidence in pharmacy could be affected. The 
initial assessment of this case is complete, and an investigation is open. The case has been allocated to a 
Case Officer who will consider the findings of the GPhC inspection and whether any further evidence is 
required. Once the investigation is complete, we will assess the evidence in line with our Threshold 
Criteria to determine whether further action against the individual pharmacist is required.  

We have opened an investigation into the concerns raised in the regulation 28 report. The Case Officer 
has been in contact with the Coroner’s Office to request documentation relating to this matter as part of 
our investigation. Once received the documentation will be assessed by the Case Officer together with 
other evidence collected as part of the investigation.  

 We hope this information is helpful. If you should require any further information, please do not 
hesitate to contact me. 

Yours sincerely 

Chief Executive and Registrar 
E

Midway Pharmacy 
46 Chapeltown 
Pudsey  
LS28 8BL 

Mr Kevin McLoughlin 
HM Senior Coroner for West Yorkshire 
Burgage Square 
Merchant Gate 
Wakefield  
WF1 2TS 

26 February 2025 

Dear Sir, 

RE: Regulation 28 Report to Prevent Future Deaths- David Joseph Crompton 
(deceased) 

Thank you for your Report to Prevent Future Deaths dated 31st December 2024, 
concerning the death of David Joseph Crompton on 13th December 2024. In advance 
of responding to your concerns, I would like to express our deep condolences to Mr 
Crompton’s family and loved ones. Midway Pharmacy is keen to assure the coroner 
and family that the concerns raised have been taken seriously and reflected upon. 

I respond to each of the matters of concern raised in your Report below: 

(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. 

We take patient safety very seriously at Midway Pharmacy and endeavour to 
dispense medication to all our patients in a safe and timely manner. Standard 
Operating Procedures (SOP) are reviewed robustly to ensure owings are identified 
promptly. Colleagues are also engaged and actively supported to ensure strict 
adherence to these processes. As part of managing owings due to supplier 
shortages, colleagues regularly attempt to source medication from a nearby Midway 
Pharmacy or by ordering from different wholesalers. Where a medication is 
prescribed by brand, and there is a clinical risk of switching brands, the patient is 
advised to try another pharmacy before obtaining an alternative brand from the GP. It 
is noted that the patient was advised to try another pharmacy due to the clinical risks 
of switching brands in epilepsy patients and the prescription was returned and made 
available for the patient to have it dispensed in another pharmacy.  

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 

 
 
 
 
 
 
 
 
 
 outcomes of patient interactions to ensure completeness of patient’s medical 
records. The wording on our SOP has also been changed to make this clearer to 
colleagues. 

(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.  

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.  

From our findings, national medication shortages played a significant role in our 
inability to obtain Mr Crompton’s medication. This is not unique to Tegretol but 
regularly impacts the profession, as detailed in the Community Pharmacy England 
Report on Medication Shortages, which can be found here: 

https://cpe.org.uk/wp-content/uploads/2024/05/Pressures-Survey-2024-Medicines-S
upply-Report-Final.pdf 

This report highlights the worsening medicine supply problems affecting pharmacy 
teams and patients daily. With significant medicine supply challenges, it is imperative 
that we get a national resolution to ensure the continued supply of high-risk 
medications that our patients so dearly need. 

(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. 

We have clear processes and procedures in place to ensure incidents are logged for 
reflection and improvement. Our medication incident reporting system is also tailored 
to support quick and clear incident logging to ensure the process is not a deterrent to 
logging in a busy pharmacy environment. Once logged, there are processes in place 
to ensure incidents are investigated within 7 days, and learnings are shared across 
the organisation and as part of Monthly Pharmacy Governance sessions. Following 
thorough checks and investigations, we have been unable to confirm the pharmacy 
was notified of the incident mentioned in April 2024. However, the case as a whole 
has provoked a great deal of reflection and emphasises the significant impact of 
national medicine supply shortages related to Tegretol. 

(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.
 in this situation were not provided.
those concerned

 Leaflets explaining the role of 

 of pharmacy

 and Mr Crompton’

We would like to reassure the coroner
Pharmacy’s commitment to clear and robust processes
management
 owings. From 3rd March 2025, where
verbally communicated to a patient and more information
 also be supplied
detail provided, the patient will
England’s Medicine Supply Leaflet. A copy of this can be found here: 

s family of Midway 
 in ensuring the safe 
 an owing has been
 is required to support the 

 with the Community

 Pharmacy 

https://cpe.org.uk/wp-content/uploads/2024/03/Medicines-supply-leaflet-March-2024-
Colour.pdf

In addition to referring patients to another
their GP for a clinical
highlight the importance
their GP is unable to support further

 pharmacy, patients are also referred to 
 reworded to 
 review. T o support this, the SOP has also been
 as the next step, if 
 hospital
 of referring patients to the local

. 

We consider that an urgent review
addressing the current medication
circumstances of this case highlight
 that the reliable
especially with high-risk  and life-saving medications. 

 of the national
 The 
 shortages experienced by the profession.

 medicines supply chain is critical in 

 supply of medication is crucial, 

 these matters to our attention. W

e hope that this response

 to you and to Mr Crompton’

s family that Midway Pharmacy has taken 

 you have raised seriously. If you have any further questions

 regarding 

Thank you for bringing
demonstrates
the concerns
our response,

 please let me know. 

Yours Sincerely, 

Superintendent
Midway Pharmacy 

 Pharmacist