Coroner Rachel Knight has raised concerns about the “very limited access” community pharmacists have to a patient’s “relevant drug history” via the Welsh clinical portal after a “well-known” drug contraindication was missed and a woman died.
In a prevention of future deaths report published on February 3, the coroner for South Wales Central said that she had “no understanding” of why pharmacists in Wales only have access to the clinical portal in “exceptional circumstances”.
If access to such information was “available routinely” in Welsh pharmacies – as it is in England – this would enable pharmacists to “properly and safely counsel patients to stop contraindicated drugs”, it said.
Read more: Coroner: Man overdoses after ‘bulk’ buying painkillers wholesale
The report comes after the contraindication of an antibiotic and a statin contributed to the death of Lyn Maher at the start of 2024.
Maher took simvastatin for high cholesterol as part of her “usual medication regime” but was prescribed clarithromycin for a chest infection in January, despite there being a “well-known contraindication between these drugs”, the inquest heard.
She was “not told to stop taking her statin by either her GP, nor by a community pharmacist dispensing the drug”, it said, adding that she was then issued a “further prescription” for the same drug a week later and again “was not told to stop taking her statin”.
Risk of future deaths
Five days later, Maher was admitted to hospital with “a variety of symptoms” and “remained in hospital” until she died, the report said.
It highlighted that there were “missed opportunities” by GPs and community pharmacists to “identify the co-ingestion of the contraindicated drugs”, along with other missed opportunities in hospital.
And this “more than minimally contributed to Maher’s tragic death” on January 23 2024, the inquest found.
Read more: Coroner warns of ‘lack’ of medicine withdrawal support services
The coroner stressed that “evidence revealed” there is “a risk that future deaths will occur unless action is taken”.
She highlighted that two separate community pharmacists “did not know” Maher was taking simvastatin when dispensing the antibiotics to her family, who collected the prescription.
“I am concerned that there is confusion and a variety of opinion amongst community pharmacists around the extent of the expectation or duty to perform ‘clinical checks’ to enable safe prescribing and what that practically entails,” she said.
“Changed the outcome”
Knight also raised concerns that there is “confusion amongst community pharmacists in Wales around the conflict between the expectation of safe prescribing/dispensing and patient confidentiality”, particularly “when someone other than the patient collects the medication”.
She concluded that “had either community pharmacist had access to Maher’s drug history, they would have noted the contraindication” and either told her, her representative or “written on the pharmacy bag” to stop the simvastatin.
“This likely would have changed the outcome for Maher,” the coroner said.
Read more: Coroner: Patient dies after ‘limited attempts’ to review opioid scripts
General Pharmaceutical Council (GPhC) chief pharmacy officer Roz Gittins said that the regulator is “reviewing the report and will respond to the coroner in due course”.
“We are saddened by Lyn Maher’s death and our thoughts are with her family,” she added.
