Coroner Emma Whitting has raised concerns that “many epilepsy patients across the country currently experience difficulties in obtaining sufficient quantities of medication to ensure optimum seizure control”.
In a prevention of future deaths report published on March 26, the senior coroner for Bedfordshire and Luton said she was informed that it is “difficult” for epilepsy patients to “obtain batch quantities” of their medication.
This is essential to “ensure they always have access to some in the event that they find they are running low or there are delays in the pharmacy processing a repeat prescription”, she added, noting that “apparently in some areas processing can take up to 10 days”.
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The report comes after the death of Paul Nash in October 2025 following an epileptic seizure after running out of his epilepsy medication.
He had missed three doses at the time of his death, the inquest heard, but the coroner noted that “the reasons for him suffering a seizure...remained unclear”.
Urgent prescription
Nash suffered with epilepsy “secondary to HSV encephalitis which he had developed in 2014 and had resulted in him sustaining a significant brain injury”, the report said.
His epilepsy had been “well controlled” with Carbamazepine, and he “had not suffered a seizure since 2016”, it continued.
In September 2025, Nash “did not appear to have requested all of his prescription” and only requested his “full prescription” on October 20, the coroner heard.
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The next day, he told brain injury charity Headway that he had taken his last dose of his epilepsy medication, prompting the charity to contact his GP on his behalf and request a prescription “urgently”.
The prescription, however, “was not ready for collection” the following day and “having not been heard from after the evening of October 22”, Nash was “found deceased in his bed” at home the next morning, the report said.
“Evidence at the scene suggested he had suffered a seizure during the night,” it added.
“Not prioritised”
In her response, Whitting said that while Headway “was reassured that the GP would be notified that [Nash] had run out of his seizure medication, this fact did not appear to have been conveyed to the GP”.
She found that the prescription “was not prioritised to ensure he received it the same day”.
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Whitting also raised concerns about the reported delays in pharmacies processing repeat prescriptions.
And she stressed that “there is a risk that future deaths could occur unless action is taken”.
Read more: Patient dies after pharmacy ‘unable to supply’ epilepsy meds for 10 days
The report was sent to Secretary of State for Health & Social Care Wes Streeting, who was given until May 14 to respond to the coroner’s findings.
“Your response must contain details of action taken or proposed to be taken, setting out the timetable for action, otherwise you must explain why no action is proposed,” Whitting said.
