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A coroner has raised concerns over delays in some pharmacies processing repeat prescriptions, after a patient died from an epileptic seizure after running out of his epilepsy medication.
Emma Whitting, senior coroner for Bedfordshire and Luton, highlighted the concerns in a ‘Prevention of future deaths’ report, published on 26 March 2026, following the death of Paul Nash, aged 58 years.
Nash died “following an epileptic seizure after running out of his epilepsy medication which meant he had missed three doses; although, the reasons for him suffering a seizure at this time remained unclear”, the coroner noted.
Discussing the circumstances of Nash’s death, the coroner wrote that Nash suffered with epilepsy secondary to herpes simplex virus encephalitis, which had developed in 2014 and resulted in a brain injury.
She added that he had been taking carbamazepine 500mg twice daily since June 2025.
“However, in September 2025, he did not appear to have requested all of his prescriptions for this and, although his full prescription was requested on 20 October 2025, on the morning of 21 October 2025, he had reported to Headway in Luton that he had taken his last dose of his epilepsy medication,” the coroner’s report said.
Despite Headway — a charity that provides support to patients with head injuries — contacting Nash’s GP and requesting an urgent prescription, this was not ready to collect the next day, the coroner said.
Nash was found dead on 23 October 2025, the report said, with evidence suggesting he had suffered a seizure during the night.
The coroner wrote to the health secretary and Department of Health and Social Care (DHSC) that Nash’s consultant neurologist had indicated patients with epilepsy across the country were experiencing difficulties in obtaining enough supply of their medication to ensure they could access this when running low or when “there are delays in the pharmacy processing a prescription”.
The consultant had indicated that pharmacies can take up to ten days to process prescriptions in some areas, she added.
The coroner also wrote to Nash’s GP surgery, Sundon Medical Centre, stating that Headway had been reassured that the GP practice would be told that Nash had run out of his medication but that “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”.
Commenting on the report, a spokesperson for Community Pharmacy England said: “This tragic and untimely death demonstrates how the current system isn’t working and now puts patients’ health at risk.
“Medicine shortages are largely outside the control of pharmacy teams, but it is vital to learn from this. We would welcome the opportunity to work with the DHSC to improve how repeat medications are managed and processed across primary care.
“In addition, the NHS could seek to raise awareness of the Pharmacy First urgent supply route for accessing medicines.”
Sundon Medical Centre and the DHSC must respond to the report by 14 May 2026, detailing action taken or proposed to be taken.
The findings of a poll conducted by Healthwatch revealed that in 2025, nearly half (45%, n=3,104) of patients had reported experiencing an issue getting their medication, while nearly two in ten (19%, n=1,335) reported experiencing prescription delays, up from 12% in 2023.
There have been ongoing shortages of epilepsy medication in the UK since 2023.
In a ‘Prevention of future deaths’ report, published on 31 December 2024, coroner’s r Kevin McLoughlin raised concerns over shortages of epilepsy medication, after patient David Crompton was unable to obtain his medication and died during a seizure on 13 December 2024.
