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A coroner has expressed concern over Welsh community pharmacists’ “limited” access to patient records, following the death of a patient whose pharmacists were unaware of her medication history.
Rachel Knight, coroner for South Wales Central, raised the concern in a ‘Prevention of future deaths’ report (PFD), published on 3 February 2026, following the death of Lyn Maher, aged 79 years, who died after being prescribed both clarithromycin and simvastatin.
Statin-induced rhabdomyolysis was one of the causes of her death, the coroner noted.
The coroner said that on 3 January 2024, Maher had been prescribed clarithromycin for a chest infection and had already been taking simvastatin for high cholesterol. The two medications are contraindicated.
“Lyn was not told to stop taking her statin by either her GP, nor by a community pharmacist dispensing the drug,” the coroner wrote.
“On 10 January [2025], she was issued with a further prescription for the same drug and again she was not told to stop taking her statin by [her] GP nor a different community pharmacist.”
Maher was admitted to Royal Glamorgan Hospital on 15 January 2024 and remained in hospital. The coroner added that at no point during her stay was Maher asked about whether she had co-ingested the drugs. Her statin continued to be given to her.
The coroner highlighted that if either of the community pharmacists had access to Maher’s drug history, “they would have noted the contraindication and either told Lyn, her representative or written on the pharmacy bag that she was to stop the simvastatin”.
“This likely would have changed the outcome for Lyn,” she said.
The coroner added: “I am concerned that community pharmacists in Wales only have very limited access to the Welsh Clinical Portal, where they can see relevant drug history and recent test results, which would enable them to properly and safely counsel patients to stop contraindicated drugs (here simvastatin with clarithromycin) but applicable more widely.
“I heard evidence that access to such information is available routinely in English pharmacies, but only in exceptional circumstances in Wales. I have no understanding of why that is the case.”
The PFD concluded that action should be taken to prevent future deaths.
The coroner copied the report to the office of the minister for Health and Social Care for Wales, Digital Health and Care Wales (DHCW) and the General Pharmaceutical Council (GPhC), who have a duty to respond to the coroner within 56 days of the letter being sent.
A spokesperson for the Welsh government commented: “Our thoughts are with the family and friends of Lyn Maher.
“All community pharmacists in Wales can access information about prescribed medicines and allergies contained in the Welsh GP Record when providing services which use the Choose Pharmacy application. This includes seeing information when making emergency supplies of medicines and undertaking clinical service consultations.
“DHCW is redeveloping the Choose Pharmacy application which will provide community pharmacists with enhanced access to information which supports them to make decisions about patients’ care by connecting to the national shared medicines record.”
Roz Gittins, chief pharmacy officer at the GPhC, said: “We are saddened by Lyn Maher’s death and our thoughts are with her family.
“We are reviewing the report and will respond to the coroner in due course.”
A spokesperson for DHCW offered their deepest sympathies to the family of Lyn Maher but did not comment further.
