Poor communication between private clinics and NHS GPs could put patients at risk of receiving “duplicate prescriptions” for medicines, a coroner has warned.
According to a prevention of future deaths report sent to NHS England (NHSE) and published this month, an inquest into the death of 23-year-old Louis Saunders in 2024 found that he was being prescribed ADHD medication by both his NHS GP and a private ADHD clinic.
“Neither organisation was aware of the other’s ongoing prescribing until the time of the inquest,” it said.
“Suicidal ideation”
The report stated that Saunders was diagnosed with ADHD by a private ADHD clinic in 2022, and was “started on medication by that clinic”.
Once “stabilised”, Saunders’ care “was transferred to his NHS GP under a shared care agreement”, it added.
It noted that Saunders “experienced negative side effects from his medication, including suicidal ideation” - and that in June 2024, he “mentioned that he had thoughts of travelling to cliffs in East Sussex”.
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Saunders “stopped taking his medication” following this, the report said, and between July and October 2024 “had contact with both his NHS GP and multiple private therapy providers”.
He received eye movement desensitisation and reprocessing treatment and “contacted his health insurer to seek talking therapy during this time”, it added.
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On October 9, 2024, Saunders “travelled from his home address in London to the East Sussex coast”, and his car was found parked in a layby later that evening.
The report said Saunders’ body was “found at the base of the cliff” the following morning and his death “was confirmed at the scene”.
“There was no medication found in his system following his death”, it added.
Coroner’s concerns
The coroner behind the report said that while Saunders “had stopped taking his medication” and “no medication was found in his system following his death”, the investigation revealed that he “was being prescribed ADHD medication by both his NHS GP and the private ADHD clinic”.
“Neither organisation was aware of the other’s ongoing prescribing until the time of the inquest”, she added.
She said that after Saunders’ care was transferred to his GP, the “plan was for the surgery to continue issuing his medication” - and that on November 6, 2023, the “surgery issued a prescription for lisdexamfetamine”.
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But Saunders had “attended an appointment at the ADHD clinic the previous day”, she added, with the clinic’s notes stating “that he was to continue on dexamfetamine”.
“Although the medications have similar names, they are distinct drugs with different dosing requirements,” she noted. “Effective management and titration are understood to be essential to ensure therapeutic benefit and limit adverse effects.”
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The coroner said her concern “relates to continuity of care” between private clinics and the NHS “once a patient has been diagnosed with ADHD, commenced on medication and subsequently transferred to GP care”.
She added that in Saunders’ case, “communication between the private sector and the NHS was insufficiently clear”.
“The situation became more complex when he continued to be seen by both the ADHD clinic and his GP,” she said. “This created opportunities for key information to be missed.”
Risk of future deaths
The coroner highlighted that “although medication was not directly implicated” in Saunders’ death, “there remains a risk that a patient may inadvertently obtain duplicate prescriptions or become confused about which medication to take”.
“Such scenarios may pose a risk of future deaths,” she said.
“As increasing numbers of patients are receiving ADHD diagnoses and commencing treatment in the private sector due to long NHS waiting times,” she added, “I am concerned about the robustness of current processes to ensure safe and continuous care following transfer to a GP.”
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The coroner concluded that “action should be taken to prevent future deaths” and that NHSE has “the power to take such action”.
A copy of the report was also sent to Nuffield Health Wellbeing Service, the ADHD Taskforce, the Royal College of Psychiatrists and the Royal Pharmaceutical Society.
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It comes after a coroner found that a man with a “dependence on cannabis” took his own life after being prescribed the drug by a private clinic using “out-of-date” GP records.
In a prevention of future deaths report published last month, the coroner said Curaleaf Clinic’s decision to continue issuing prescriptions of medicinal cannabis “was based on incomplete information”.
