Paul Nash

HM Coroner Emma Whitting 
The Court House, Woburn Street, Ampthill, Bedfordshire MK45 2HX 

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

06 May 2026 

Dear Ms Whitting,  

Thank you for the Regulation 28 report of 19 March 2026 sent to the Secretary of State / the 
Department of Health and Social Care about the death of Paul Nash. I am replying as the 
Minister with responsibility for primary care.       

Firstly, I would like to say how saddened I was to read of the circumstances of Paul Nash’s 
death and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention.  

The  report  raises  concerns  over  the  ability  for  epilepsy  patients  to  obtain  sufficient 
medication  in  a  timely  manner  to  ensure  optimum  seizure  control.  You  have  raised  that 
delays in being able to access medicines is a risk that affects many epilepsy patients across 
the country.  

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns. 

General practice is commissioned and performance-managed by NHS England, with 
responsibility delegated to Integrated Care Boards, who are expected to work with 
practices to provide support and agree improvement plans where performance concerns 
arise. Where issues persist, commissioners can intervene and use contractual levers, 
including remedial action, to ensure safe and appropriate patient care.  

This Government is committed to improving care for people with neurological conditions, 
including those with epilepsy, and ensuring they receive the support they need. It is vital 
that we ensure that they, along with their families and carers, receive high-quality, 
compassionate care and access to the latest services and treatments. Sudden 
Unexpected Death in Epilepsy (SUDEP) is a rare but devastating outcome, and the 
Government recognises the profound impact it has on individuals, families, and the wider 
epilepsy community. We are committed to reducing the risks associated with epilepsy, 
improving understanding of SUDEP, and ensuring that people with epilepsy receive safe, 

  
  
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
  
 high-quality care. The Royal College of GPs aims to raise awareness of SUDEP amongst 
GPs and other primary care professionals, through its e-learning modules on SUDEP and 
seizure safety, which were developed in collaboration with SUDEP Action. 

At a national level, there are a number of initiatives supporting service improvement and 
better care for patients with epilepsy, including the RightCare Epilepsy Toolkit, the Getting 
It Right First Time Programme for Neurology and the recently completed Neurology 
Transformation Programme.     

One key focus of the RightCare Epilepsy Toolkit is reducing epilepsy-related deaths, 
including SUDEP. The toolkit includes several recommendations regarding identifying 
those who are most at risk of an epilepsy-related death and preventing SUDEP. The 
RightCare Epilepsy Toolkit emphasises structured risk assessment and the importance of 
routine, proactive conversations about SUDEP within care pathways. The toolkit signposts 
to practical resources such as the SUDEP & Seizure Safety Checklist, which assists 
clinicians in discussing and recording risk-reduction advice with patients and their families. 
This approach aligns with National Institute for Health and Care guidance, which advises 
that clinicians should discuss the individual risk of epilepsy-related death, including 
SUDEP, with people diagnosed with epilepsy at the time of diagnosis and revisit these 
discussions as part of ongoing care. Conversations should cover individual risk factors, 
such as uncontrolled seizures, missed medication, and nocturnal seizures, and provide 
practical advice on reducing these risks. This approach ensures patients and families are 
fully informed and able to take steps that improve safety and reduce the likelihood of 
SUDEP. 

The Department recognises that delays in pharmacies processing repeat prescriptions can 
result in patients unexpectedly running out of vital medicines. That is why all community 
pharmacies providing dispensing services for NHS patients in England are required to 
dispense medicines for patients on demand with reasonable promptness. This is set out in 
regulations and within the terms of service for all pharmacies on the NHS Pharmaceutical 
list.  

This recognises that a pharmacy might need to order a medicine in when they do not have 
is in stock. If this occurs, the pharmacy is required to inform the patient of this delay and 
when the pharmacy expects the prescription to be dispensed. This should enable the 
patient to make an informed decision whether they would be better off taking their 
prescription to a different pharmacy. 

Prescriptions are generally written for a month's supply, with the onus on the patient to 
reorder their medicines in a timely way. Longer duration of supply (e.g. 56 and up to 84 
days) is also possible, based on clinical decision making, balancing the risks of stock piling 
with the benefit of ensuring ongoing care.  

The NHSApp is the preferred route to order repeat prescriptions and a variety of NHSApp 
champions (including some pharmacy staff) have been trained across primary care 
settings to promote its use. A community pharmacy can advise patients on how to make 
requests for prescriptions and there are options through the NHSApp to enable designated 

 
 
 
 
 carers to proxy-order prescriptions on a patient’s behalf. A patient may agree with their GP 
to nominate a particular pharmacy to dispense their medicines using electronic repeat 
dispensing processes. This allows the pharmacy to supply a patient on a stable medication 
regimen in instalments over a 12-month period without the need to keep re-ordering via 
their GP. This should reduce the risk of missing to an order and the pharmacy can 
proactively work with the patient to ensure a regular supply in advance of running out 
based on their prescription and preferences, e.g. to help manage any holiday periods. 

The Department recognises that delays in prescriptions being sent by GPs, such as in 
Paul Nash’s tragic case, can result in patients being left without vital medication. 
Provisions are in place to prevent patients being left in this situation. If a patient needs to 
access an urgent supply of their medicines, then there are a range of options available, 
which can be found at Emergency prescriptions - NHS.   

As set out in the Human Medicines Regulations 2012 pharmacists can make an 
emergency supply of medication without a prescription at the request of a patient or 
prescriber. Emergency supplies can be made if the pharmacist deems this to be clinically 
appropriate and the item is in stock, with some limited restrictions including some related 
to controlled drugs. 

The Urgent Medicine Supply (UMS) element of the NHS Pharmacy First Service uses this 
legal route for patients who urgently need a medicine they are regularly prescribed through 
NHS111, both through the telephone service and online service. NHS 111 can work with 
carers or agencies as in the case of HEADWAY for Paul Nash to support requests for 
urgent prescriptions if the patient is unable to do this themselves. Following an initial rapid 
triage the patient will be referred to a pharmacy in a location nearest to them where they 
can obtain a supply that same day or in time before the next dose whichever is clinically 
appropriate. 

Once referred, the patient will receive a consultation with the pharmacist. Where it is 
appropriate for the emergency supply to be made, and the medicine is in stock, the 
pharmacist will arrange for the patient to collect the item. If the medicine is not in stock, the 
pharmacist must proactively assist the patient by identifying another local pharmacy that 
has the medicine available and provides the service and forward the electronic referral. 
This may involve checking stock availability through local pharmacy networks or contacting 
nearby pharmacies directly. If all else fails and the situation is critical, patients should be 
directed to the nearest A&E department or most appropriate care setting to receive 
treatment. 

The National Institute for Health and Care Excellence has also published guidance for 
pharmacists on making an emergency supply of medication, which reinforces the guidance 
of the Royal Pharmaceutical Society which states: “The pharmacist should consider the 
medical consequences of not supplying a medicine in an emergency” and “If the 
pharmacist is unable to make an emergency supply of a medicine the pharmacist should 
advise the patient how to obtain essential medical care.” 

 
 
 
 
 This guidance is further supported by the service specification for the NHS Pharmacy First 
service that was launched on 31 January 2024 (NHS England » Launch of NHS Pharmacy 
First advanced service). In cases where medication that is urgently required is not in stock 
at the pharmacy, the service specification states that, with the agreement of the patient, 
the pharmacist should identify another pharmacy that provides the service and forward the 
electronic referral to them (see 4.19). If the patient is unable to get to the premises, the 
pharmacist must ensure that the patient is able to obtain the supply in a timely manner by 
discussing all reasonable options for accessing their medicines (see 4.20). 

A review in January this year of the Pharmacy First urgent medicines pathway has been 
undertaken in the context of time-critical medicines in response to a prevention of future 
deaths report for a patient who died from Sudden Unexpected Death in Epilepsy after he 
was unable to obtain an urgent prescription for his epilepsy medication. A time-critical 
medicine is one that must be given or taken at a specific time, where a delay in receiving 
the dose or an omission of the dose entirely may lead to a serious patient harm. As a 
result, a number of actions have been taken by NHS England: 

• 

Issued a patient safety incident notification to all community pharmacy contractors 
and their pharmacy teams about the importance of supplying time-critical 
medicines. 

•  Reviewed the service specification that underpins the service and identified where 
text can be uplifted to emphasise the importance of time-critical medicines supply. 
The next steps are to consult with Community Pharmacy England on the proposed 
changes and work with the Department to publish a refreshed document later this 
year with wider contract changes for 26/27. 

•  Worked with regional pharmacy clinical leads to engage with Integrated Care Board 
pharmacy commissioning teams and Local Pharmaceutical Committees to share 
learning from the patient safety incident notification as well as engage with the 
Community Pharmacy Patient Safety Group that coordinates learning across the 
sector through Pharmacy Superintendents and the National Pharmaceutical 
Association. 

The Department recognises that awareness of emergency supply provisions amongst both 
patients and pharmacy staff can be improved. The Department is committed to working 
with the pharmacy sector to improve awareness and ensure patients can access 
emergency supplies when necessary to prevent harm or death. We are currently in 
consultation with the sector representative body, Community Pharmacy England, on the 
2026/27 Community Pharmacy Contractual Framework. As part of this consultation we will 
take into account learnings from Paul Nash’s death. 

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely, 

 
 
 
 
  
 MINISTER OF STATE FOR CARE

08 May 2026

Natalie Shirran
Principal Coroner’s Officer
Bedfordshire & Luton Coroner’s Service

Prevention of Future Death Report following Inquest touching on the death of Mr
Paul Nash.

Dear Ms Shirran

I am writing to reply to the documents sent to us recently relating to the above-named
deceased patient and subsequent inquest:

1. Regulation 28 Report to Prevent Future Deaths dated 19 March 2026

In section 5 of the Regulation 28 you have stated the following: Coroners Concerns.

During the course of the investigation my inquiries revealed matters giving rise to concern.

In my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:

(brief summary of matters of concern)

For GP Surgery only:

1.  During the phone call with the Surgery on 21 October 2025, HEADWAY made it

clear to the Surgery that the Deceased had run out of his Carbamazepine (seizure
medication) completely and, although he had taken that morning's dose, if he did
not receive more medication that day he would not have his evening dose or any
other doses. Although HEADWAY was reassured that the GP would be notified
that the Deceased had run out of his seizure medication, this fact did not appear to
have been conveyed to the GP and the prescription was not prioritised to ensure
he received it the same day.

We were saddened to learn of the death of Mr Nash on the 23 October 2025. We have
taken this matter extremely seriously and had commenced actions immediately after the
Inquest and before the Regulation 28 Report was issued.
These are the actions taken and details of plans to take forward.

 Action to address the concern regarding the medication request made by Headway
and the fact the reassurance that the GP would be notified and the prescription
prioritised did not happen.

Following Mr Nash’s death the practice raised a Significant Event Concern and have
revisited this on a number of occasions.

Critical Medications list.  We have created a Critical Medication List where missing of
doses may lead to significant harm.

Prescribing instructions to clearly state indication and total dose.  For these
medications the repeat template must state what the medication is for (indication) after the
dose so that both the reception team and any clinician unfamiliar with a patient will know
why the medication is being taken. This has been completed for all epilepsy medications.

Additional safeguards for split-strength medication regimens.  Where patients are
prescribed more than one strength of a given critical medication the practice will ensure
that prescribing instructions clearly state the total dose on each repeat template of that
medication and make it explicit that the doses are to be taken together. This is intended
to reduce the risk of only one item being issued or requested in error. This also makes
clear to reception staff who are not medically trained what the medication is used for and
also to clinicians who may not be familiar with the patient for whom they are signing
medication. The SEA identified this as an important learning point following this incident.
This has been completed for all epilepsy medications.

Example:

Carbamazepine 200mg tablets- Take one tablet twice daily for epilepsy in addition to
100mg tablets to make a total dose of 300mg twice daily.

Carbamazepine 100mg tablets- Take one tablet twice daily for epilepsy in addition to the
200mg tablet to make a total dose of 300mg twice daily.

Critical medication escalation process- the practice is introducing a formal process for
identifying and escalating requests relating to critical medications including anti-epileptic
medication. Where a patient reports that they have run out, or are about to run out of such
medication, this will be treated as a priority medication safety issue and escalated
promptly for same day review by an appropriate clinical or prescriber. Where such a task
is sent to the Duty Clinician it will be flagged as urgent and an instant message will also

 be sent to that clinician advising of the urgent task requiring attention. Training has been
undertaken in this and we are currently monitoring and auditing to ensure that this is
happening.

Written medication requests only. The practice has reinforced that medication requests
should be submitted in writing, including through approved electronic routes or the triage
system, rather than being taken over the telephone. This is intended to improve accuracy,
create a clear audit trail and reduce the risk of misunderstanding or omission when
medications and dosages are requested. Patients or their carers may request ’seizure
medication’ or ‘heart medication’ which could lead to errors as clerical staff are not
medically trained.

Repeat dispensing / batch prescribing for suitable patients. For patients prescribed
long term critical medication, the practice will consider whether repeat dispensing or batch
prescribing with future dated repeat prescriptions for up to six months is appropriate,
particularly where patients may have memory difficulties, cognitive impairment, or other
vulnerabilities that place them at risk of running out of medication. This will be assessed
on a case by case basis to ensure suitability and safety. Where patients have experienced
difficulty obtaining medication on time the practice will consider prescribing a one-off extra
medication prescription to provide patients with a month of their time critical medication in
hand.

Enhanced support for vulnerable patients. Where a patient is known to have memory
difficulties, cognitive impairment, brain injury and / or reliance on relatives / carers for
medication support, the practice will consider whether additional medication safety
measures are needed. This may include review of dispensing arrangements, earlier
intervention where requests are irregular and clear recording of any relevant support
arrangements.

Informing Epilepsy Patients of the Charlie Card - this is a self advocacy tool designed
to assist individuals with epilepsy who find themselves without their regular anti-seizure
medications. It highlights the legal framework under the Human Medicines Regulations
2012, allowing patients to request an emergency supply of anti-seizure medications from
any pharmacy without a prescription, provided certain conditions are met. The card serves
as a reminder to pharmacists of their legal duties and aims to ensure that patients can
access life- saving medications quickly and efficiently. The Charlie Card is available free
through the charity shop of SUDEP Action and individuals can also download a copy.

Staff training on critical medications and escalation. Reception and administrative
staff have received and will continue to receive further training on:

-recognising critical medications,

 -identifying and issuing split strength medications on repeat

-escalating concerns promptly to the duty doctor or prescribing clinician

-checking communication carefully to ensure all requested items are clearly identified.

The practice recently spent a PLT (Protected Learning Time) session on Reception Safety
training (25/03/26) which included prescription requests safety training as highlighted by
the significant event. This included working through procedures and various scenarios

Clear patient information regarding repeat turnaround times The practice will
continue to ensure that patients are clearly informed that repeat prescriptions require a
two working days for surgery processing and that pharmacies require additional time for
dispensing. This information will be displayed on the website and in reception to
encourage timely ordering and reduce the risk of medication running out.

Pharmacy communication for urgent critical medication. Where a patient has run out
of critical medication and an urgent prescription is issued, the practice will ensure that the
urgent nature of the request is clearly highlighted with the pharmacy to support prompt
dispensing.

Local Pharmacies have access to our bypass back office telephone number.

We also have a dedicated pharmacy direct email in box (as required by the new GP
contract for 2026)

Audit and Review. The practice will undertake a review of these changes after
implementation to ensure they are embedded and effective. This will include monitoring
compliance with the new process for urgent critical medicines, checking the use of clear
dosage wording for split-strength prescriptions and reviewing whether staff are following
the written request and escalation process consistently.

Yours sincerely

On behalf of Sundon Medical Centre.