Lyn Maher

General
Pharmaceutical
Council

Rachel Knight
HM Coroner for South Wales Central Coroner Area
By email only to: Coroneradmin@rctcbc.gov.uk

31 March 2026

Dear Rachel Knight
In the matter of Lyn Maher

Thank you for sending us the Regulation 28 report following the inquest touching the death of Lyn
Maher.

By way of background the GPhC is the independent regulator for pharmacists, pharmacy technicians
and pharmacies in Great Britain. Our role 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.

Action we have taken

It may be helpful to set out the action we have taken in respect of the pharmacies that supplied
clarithromycin to Lyn and the pharmacists involved in making the supplies.

Inspection

Since January 2024 we inspected both pharmacies and found they were meeting our Standards for
registered pharmacies which set the minimum requirements to create and maintain the right
environment for the safe and effective practice of pharmacy.

We have also spoken with the Superintendent Pharmacists for both pharmacies to establish the actions
they have taken to address the risks identified and prevent a recurrence.

One Superintendent Pharmacist told us they had:
e Introduced prompt cards in the pharmacy for use when dispensing macrolide antibiotics (which
include clarithromycin), so that when patients present with prescriptions for these medicines,

they are asked if they are also taking statins. If the answer is positive, the patient is then
counselled and advised to stop taking the statin whilst taking the antibiotics.

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e Across their chain of pharmacies, they have raised awareness of the interactions between
clarithromycin and statins.

Another Superintendent Pharmacist told us they had written to their staff sharing the circumstances and
learnings from the inquest and asked staff to reflect upon how they can minimise risk from interactions
between the medicines they supply and medicines the patient already takes, especially when they may
not have access to the patient’s medical records to establish the patient’s medication regime. In those
circumstances the Superintendent Pharmacist advised staff to consider speaking to the patient’s GP to
obtain a full medicine history before making a supply, or alternatively suggested staff can access the
software platform in England to gain information about the patient’s medication or in Wales, to access
data from the Choose Pharmacy platform.

Fitness to practise processes

Our responsibilities include ensuring that pharmacists and pharmacy technicians we register are fit to
practise. Being fit to practise involves having the skills, knowledge, health and character to perform their
role safely and effectively and behaving in an ethical and trustworthy matter. Pharmacists and pharmacy
technicians must also meet our Standards for pharmacy professionals which describe how safe and
effective care is delivered.

Where we receive information which may impact upon an individual’s fitness to practise, we can
investigate. If our investigation identifies evidence demonstrating a risk of ongoing harm to patients and
the public or suggests public confidence in pharmacy will be undermined if action is not taken, a range
of measures are available to address the concerns, including (but not limited to) imposing restrictions on
an individual's ability to practise.

In September 2025 we were contacted by the Court and informed of the circumstances in Lyn’s case and
asked to produce a witness statement for the inquest. At the conclusion of the inquest, the Court shared
the inquest evidence enabling us to investigate whether there are any implications for the fitness to
practise of the individuals involved. We started our investigations shortly after the inquest concluded to
avoid the risk of potential prejudice to either the inquest or our fitness to practise investigations. As a
result, our investigations are at an early stage and we therefore cannot indicate what the outcome will
be. We aim to complete fitness to practise investigations as soon as possible and usually within six
months of receiving the concern unless the matter is especially complex, in which case investigations
may take a little longer to conclude.

It is important to note that fitness to practise is forward looking. The purpose of fitness to practise
investigations and proceedings is not to punish individuals for their past actions or omissions, rather it is
intended to establish whether an individual can demonstrate the knowledge, skills, health and proper
professional conduct and behaviour needed to provide safe and effective care.

Raising awareness

In December 2025 we wrote to all pharmacy owners, pharmacists and pharmacy technicians drawing
their attention to emerging patient safety concerns we had identified. We asked them to review the

information provided and to reflect on actions they may need to take to address the issues. We also
signposted them to available resources they may find helpful.

Whilst not directly referencing Lyn’s case, one of the areas of concern we highlighted was an incident
involving a patient routinely prescribed a long-term medicine who had been provided with an antibiotic
where an interaction was present. In this example we explained that these interactions can result in
serious patient harm and, although rare, life-threatening outcomes.

We acknowledged that pharmacy teams may not always have access to a patient’s complete medication
history, in which case they should take all reasonable steps to ensure supplies of medication made are
safe and appropriate. Steps to take include consultations, checking records where possible, providing
counselling, and communicating with other healthcare professionals.

Our message emphasised that pharmacists and pharmacy technicians should ensure that interactions
are thoroughly checked and patients are counselled on the initiation of medication and made aware if
any medication needs temporarily pausing.

Reflections

Interactions and counselling

We recognise that most medicines have the potential to interact with other medicines, as well as with
certain foods or medical conditions. Not all interactions are harmful; some can be clinically beneficial
and may be used to optimise therapeutic outcomes or reduce adverse effects.

In line with our standards around person-centred care, pharmacists and pharmacy technicians should
use their professional judgement to assess the clinical relevance of potential interactions and provide
appropriate advice tailored to the individual or their carer. Given the breadth and complexity of
potential interactions, within a busy pharmacy setting it is not feasible in routine practice to counsel
patients on every possible interaction. Priority should be given to those interactions that are clinically
significant and relevant to patient safety, ensuring that information is communicated clearly and
supports the safe and effective use of medicines.

Where interactions can be harmful as is the case with clarithromycin and statins, our expectation is that
before supplying medicine to the patient or their representative, pharmacy staff will provide
appropriate advice and counselling, including advising that if the patient takes statins, they should be
stopped until after the patient finishes the short course of antibiotics. This approach ensures the
important patient safety message is communicated.

In line with your concerns, we note that there were many missed opportunities whereby neither the
pharmacists, GP or hospital clinicians identified Lyn had been prescribed clarithromycin and statins at
the same time. This suggests there is a need to raise further awareness more widely to effect change
and improve patient safety. We have highlighted below our proposed next steps in this regard.

Pharmacist education and training

We accredit programmes of initial education and training delivered by the Schools of Pharmacy,
including the Master of Pharmacy degree.

Students enrolled on the course are taught learning outcomes which include (but are not limited to) the
following:

e consider the quality, safety and risks associated with medicines and products and take
appropriate action when producing and supplying them

e appraise the evidence base and apply clinical reasoning and professional judgement to make
safe and logical decisions which minimise risk and optimise outcomes for the person

e critically evaluate and use national guidelines and clinical evidence to support safe, rational and
cost-effective procurement for the use, and prescribing (by others) of, medicines, devices and
services.

During their degree, students learn what is involved in conducting a clinical check.

After successfully completing their degree, trainees then undertake fifty- two weeks of Foundation
Training designed to support them to further develop and demonstrate the skills, knowledge and
behaviours expected of pharmacists. It also gives them the opportunity to further apply their academic
knowledge in practice settings. During this period trainees are supervised in practice and must
demonstrate that they meet our learning outcomes.

During their academic studies and in supervised practice prior to registering with us, students and
trainees learn about and perform clinical checks, the purpose of which is to ensure the clinical safety
and effectiveness of the medicine for the patient. By the time they register with us, we expect they can
safely and competently perform all aspects of their role.

Trainees also need to sit and pass the Common Registration Assessment (CRA) before they can apply for
registration with us. The CRA is jointly delivered by us and the Pharmaceutical Society of Northern
Ireland (the regulator of pharmacists and pharmacies in Northern Ireland). The purpose of the CRA is to
assure the public that trainees have met a common threshold of applying the knowledge and skills
necessary for safe and effective person-centred care and professional practice in the UK at the point of
registration.

Once registered, pharmacists and pharmacy technicians must record what they have done each year to
keep their knowledge and skills up to date and reflect on how they have put this into practice. This is
captured within their revalidation submission to us. Where a pharmacist or pharmacy technician
identifies aspects of their knowledge, skills or practice that require further development, our
expectation is that they will set out the actions they have taken to address the issue as part of their
revalidation.

Clinical checks and the role of the Royal Pharmaceutical Society

Guidance on what is expected when assembling medicines, undertaking a clinical check, and handing
out medicines is produced by the Royal Pharmaceutical Society (RPS), the professional leadership body
for pharmacists in Great Britain. Currently it is only available to pharmacists who pay to be members of
the RPS.

Access to patient records

We agree that if pharmacies in Wales had routine access to appropriate patient medical records the
dispensing process should identify and mitigate the risk of harmful interactions between prescribed
medications by ensuring pharmacy staff have the information necessary to provide appropriate advice
and counselling to patients or their representatives. It is important to note, that even if access were
available, it would still be contingent on patient consent.

While community pharmacies in Wales have access to the platform software used to view patient
information, they are expected to access GP records only when delivering an NHS-commissioned service
and only with the patient’s consent. We understand that access outside of these services should not
normally occur unless it is needed in an emergency.

We note that you have shared your concerns with Digital Health and Care Wales who are well placed to
explain their requirements for pharmacies in Wales providing NHS services to access patient records and
any planned changes to access.

We support and encourage changes to improve access for pharmacy teams to have the information they
need to keep patients and the public safe.

Action we will take

We have reflected upon the evidence received during the inquest and the concerns you have expressed
within the Regulation 28 report.

In terms of next steps, within the next six weeks we will be writing to the Statutory Education Bodies in
Great Britain who are responsible for delivering the Foundation Training year and to the Deans of the
Schools of Pharmacy across the UK to share the learnings in Lyn’s case and from other inquests, and to
seek their support in raising awareness of the important patient safety issues identified with students
and trainees.

We are also in discussions with the Chief Pharmaceutical Officer for Wales and will be collaborating in
producing a joint communication to be sent to pharmacists and pharmacy technicians in Wales to
further raise awareness of the issues.

We regularly liaise with the RPS and during these meetings, we discuss how we can work together to
support patient safety and consider any messaging that needs to be shared with pharmacists and
pharmacy technicians. This case has been specifically considered as part of our meetings.

We regularly produce updates for pharmacists and pharmacy technicians on key learnings and insights
in Regulate articles which are sent electronically. We will be producing a Regulate article dedicated to
appropriate counselling in connection with interactions and higher-risk medicines which will be
published in May 2026.

| hope this information is helpful.

Yours sincerely

Chief Executive and Registrar