Man, 32, suffers fatal seizure after spending last hours of life ‘begging’ GP and pharmacist for medication

A MAN with epilepsy suffered a fatal seizure after spending the last hours of his life “begging” his GP, NHS 111 and a pharmacy for his medication.

Charlie Marriage, 32, passed away in June 2021, after running out of his epilepsy drugs.

He suffered a fatal seizure in his flat in Camberwell, South London, having spent two days frantically contacting his GP, NHS 111 and a Superdrug pharmacy in order to get hold of his medication Fycompa.

Charlie had been relying on the 8mg tablets to manage his condition for two years, with his mum Henrietta describing the drugs as a “game-changer”.

He was first diagnosed with epilepsy at age 14.

An inquest into the 32-year-old’s death flagged failures committed by Charlie’s GP, NHS 111 call handlers and a locum pharmacist working in the Camberwell pharmacy at the time.

Delivering his verdict at London Inner South Coroner’s Court on January 21, Coroner Xavier Mooyaart said “there were a significant number of failings” and “many missed opportunities” that contributed to Charlie’s death.

But he didn’t go as far as saying Charlie wouldn’t have died if these failings hadn’t occurred, The i reported.

Instead, the coroner ruled that sudden death in epilepsy (SUDEP) was the cause.

Fycompa tends to be ordered in specifically for patients and would not likely have been available locally, the coroner added.

Mr Mooyaart said Charlie’s lack of medication had probably contributed to his death by increasing his risk of seizure and their severity.

The tragic incident took place during the pandemic.

Charlie had been told to isolate by NHS Test and Trace on Thursday 24 June, 2021.

The 32-year-old, who was studying for a Masters in occupational therapy at Brunel University in Uxbridge, Middlesex, took the Covid alert advice seriously, and stayed in his south London flat.

But he realised by isolating he would be without his medication over the weekend, as his prescription had been delivered to his university campus pharmacy and he couldn’t travel to collect it.

He called his GP surgery first thing the following day to request an emergency supply of Fycompa 8mg tablets to cover him until the pharmacy reopened on Monday and arranged for a friend to collect his medication.

Admin staff told him the GP would call him back in an hour.

After two hours and no call, he called again, only to be put on hold and then cut off.

He called again and was told someone would call him back.

When no one called, he reached out for a fourth time and was told he had to make an online request before the GP would issue an emergency prescription.

Charlie did this but the surgery closed for the weekend and he still had no medication.

He then called NHS 111 believing they would help him to access his medication.

In total, he called them five times and explained his full situation to separate call handlers.

He was eventually told he’d be able to collect his medication for a nearby Superdrug pharmacy.

Henrietta met her son at the shop as he was too anxious to enter and said the pair tried for two hours to get hold of his medication, unaware the pharmacist could not access the system needed to fulfil the NHS 111 emergency prescription service.

Charlie became “very, very stressed” during this time, Henrietta told The i, and they later discovered the pharmacy didn’t have any Fycompa in stock.

Charlie took two out of date, lower dose pills he’d stashed at his girlfriend’s flat, hoping they’d be enough to tide him over till Monday.

When he received a call from an NHS 111 call handler later on asking if he still wanted a doctor to call him, he said no.

It’s believed that just 90 minutes later, while at home alone, he suffered a fatal seizure.

“Charlie spent the last morning of his life begging for medication,” said Henrietta during an inquest hearing in December last year.

She added his final hours had been filled with the stress of trying to get hold of his lifesaving tablets.

Coroner’s findings

Mr Mooyaart said that DHU Healthcare, which runs NHS 111 services, should have been able to identify that Charlie needed an urgent callback from a clinician, not a non-medically qualified call handler.

The urgency of Charlie’s situation should have been apparent from his calls to the GP practice and his online repeat prescription request, the coroner found.

He also identified failures in the GP practice’s process to ensure an urgent repeat prescription request was identified and escalated.

As for the Camberwell pharmacy, it was found to have made “a simple failure” when it opened for business without being able to support patients needing emergency medication.

The coroner noted that it was two weeks behind on on prescriptions, and that the locum pharmacist, who was new, didn’t know how to access the computer system which held the NHS 111 referral for Charlie’s medication.

Mr Mooyaart suggested that the pharmacist could have told Charlie to go to A&E or other pharmacies.

He issued a prevention of future deaths report directed at NHS England, calling on the health service to examine how they triage patients in situations like Charlie’s.

NHSE has 56 days to respond.

An NHS England spokesperson told The Sun: “NHS England extends its deepest sympathies to the family and loved ones of Charlie Marriage.

“We will carefully consider the issues raised in a Prevention of Future Deaths Report by HM Coroner upon receipt and will respond in due course.”

The Sun has also contacted DHU Healthcare and Superdrug for comment.

A spokesperson for Superdrug told The i: “Our thoughts and condolences are with Mr Marriage’s family.

“The safety and well-being of our patients remain our top priority. We take all necessary steps to ensure the highest standards of service are upheld at all times.

“The independent locum pharmacist involved in this case no longer works with us.”

Henrietta fears that other people who find themselves without vital meds out of business hours could meet the same tragic fate as Charlie.

Will Marriage, Charlie’s father, said: “We can’t do anything about Charlie now. We’re all very sad about it.

“But if anything good can come out of this, if it could mean someone else in the future doesn’t have to have those waits and those difficulties in getting necessary medication then that would be really helpful.”