A MAN with epilepsy suffered a deadly seizure after spending the final hours of his life ‘begging’ his GP, NHS 111 and a pharmacy for his remedy.
Charlie Marriage, 32, handed away on June 2026, 2021, after operating out of his epilepsy medication.
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He suffered a deadly seizure in his flat in Camberwell, South London, having spent two days frantically contacting his GP, NHS 111 and a Superdrug pharmacy as a way to pay money for his remedy Fycompa.
Charlie had been counting on the 8mg tablets to handle his situation for 2 years, along with his mum Henrietta describing the medication as “game-changer”.
He was first recognized with epilepsy at age 14.
A inquest into the 32-year-old’s loss of life flagged failures dedicated by Charlie’s GP, NHS 111 name handlers and a locum pharmacist working within the Camberwell pharmacy on the time.
Delivering his verdict at London Inside South Coroner’s Courtroom on January 21, Coroner Xavier Mooyaart stated “there have been a big variety of failings” and “many missed alternatives” that contributed to Charlie’s loss of life.
However he did not not go so far as saying Charlie would not have died if these failings hadn’t occurred, The i reported.
As a substitute, the coroner dominated that sudden loss of life in epilepsy (SUDEP) was the trigger.
Fycompa tends to be ordered in particularly for sufferers and would not going have been accessible regionally, the coroner added.
Mr Mooyaart stated Charlie’s lack of remedy had most likely contributed to his loss of life by rising his danger of seizure and their severity.
The tragic incident happened in the course of the pandemic.
Charlie had been informed to isolate by NHS Take a look at and Hint on Thursday 24 June, 2021.
The 32-year-old, who was finding out for a Masters in occupational remedy at Brunel College in Uxbridge, Middlesex, took the Covid alert recommendation significantly, and stayed in his south London flat.
However he realised by isolating he could be with out his remedy over the weekend, as his prescription had been delivered to his college campus pharmacy and he could not journey to gather it.
He referred to as his GP surgical procedure very first thing the next day to request an emergency provide of Fycompa 8mg tablets to cowl him till the pharmacy reopened on Monday and organized for a pal to gather his remedy.
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Admin workers informed him the GP would name him again in an hour.
After two hours and no name, he referred to as once more, solely to be placed on maintain after which minimize off.
He referred to as once more and was informed somebody would name him again. When nobody referred to as, he reached out for a fourth time – to be informed he needed to make a web based request earlier than the GP would concern an emergency prescription.
Charlie did this however the surgical procedure closed for the weekend and he nonetheless had no remedy.
What to do if somebody if somebody is having a seizure
If you happen to see somebody having a seizure or match:
Solely transfer them in the event that they’re at risk, reminiscent of close to a busy street or sizzling cookerCushion their head in the event that they’re on the groundLoosen any tight clothes round their neck, reminiscent of a collar or tie, to assist breathingTurn them on to their facet after their convulsions stopStay with them and speak to them calmly till they recoverNote the time the seizure begins and finishes
If the particular person is in a wheelchair, put the brakes on and go away any seatbelt or harness on. Assist them gently and cushion their head, however don’t attempt to transfer them.
Don’t put something of their mouth, together with your fingers. They should have no meals or drink till they’ve absolutely recovered.
Name 999 and ask for an ambulance if:
It is the primary time somebody has had a seizureThe seizure lasts longer than is common for themThe seizure lasts greater than 5 minutes, should you have no idea how lengthy their seizures normally lastThe particular person doesn’t regain full consciousness, or has a number of seizures with out regaining consciousnessThe particular person is significantly injured in the course of the seizureThe particular person has problem respiratory after the seizure
Supply: NHS
He then referred to as NHS 111 believing they might assist him to entry his remedy.
In whole, he referred to as them 5 instances and defined his full state of affairs to separate name handlers.
He was ultimately informed he’d have the ability to accumulate his remedy for a close-by Superdrug pharmacy.
Henrietta met her son on the store as he was too anxious to enter and stated the pair tried for 2 hours to pay money for his remedy, unaware the pharmacist couldn’t entry the system wanted to fulfil the NHS 111 emergency prescription service.
Charlie turned “very, very burdened” throughout this time, Henrietta informed The i, and so they later found the pharmacy did not have any Fycompa in inventory.
Charlie took two outdated, decrease dose tablets he’d stashed at his girlfriend’s flat, hoping they’d be sufficient to tide him over until Monday.
When he acquired a name from an NHS 111 name handler in a while asking if he nonetheless needed a health care provider to name him, he stated no.
It is believed that simply 90 minutes later, whereas at house alone, he suffered a deadly seizure.
“Charlie spent the final morning of his life begging for remedy,” Henrietta the coroner’s courtroom throughout a listening to in December final 12 months, saying his last hours had been marred by the stress of making an attempt to pay money for his lifesaving tablets.
Coroner’s findings
Mr Mooyaart stated that DHU Healthcare, which runs NHS 111 companies, ought to have been capable of determine that Charlie wanted an pressing callback from a clinician, not a non-medically certified name handler.
The urgency of Charlie’s state of affairs ought to have been obvious from his calls to the GP follow and his on-line repeat prescription request, the coroner discovered.
He additionally recognized failures within the GP follow’s course of to guarantee an pressing repeat prescription request was recognized and escalated.
As for the Camberwell pharmacy, it was discovered to have made “a easy failure” when it opened for enterprise with out having the ability to help sufferers needing emergency remedy.
The coroner famous that it was two weeks behind on on prescriptions, and that the locum pharmacist, who was new, did not know the best way to entry the pc system which held the NHS 111 referral for Charlie’s remedy.
Mr Mooyaart steered that the pharmacist might have informed Charlie to go to A&E or different pharmacies.
What’s SUDEP?
SUDEP is the sudden, surprising loss of life of somebody with epilepsy.
They’re in any other case wholesome, and no different explanation for loss of life will be discovered.
Medical doctors know that SUDEP is related to seizures, however nobody is aware of the precise trigger and there could also be no single rationalization.
The situation is uncommon, affecting round 550 adults with epilepsy within the UK annually.
Some issues are understood to place you at elevated danger. These embrace having uncontrolled seizures, sleep seizures, not taking medication usually, alcohol or drug dependency and residing alone.
Seizure alarms or displays, sleeping in your again and utilizing security pillows might help, consultants say.
Supply: Epilepsy Motion
He issued a prevention of future deaths report directed at NHS England, calling on the well being service to look at how they triage sufferers in conditions like Charlie’s.
NHSE has 56 days to reply.
An NHS England spokesperson informed The Solar: “NHS England extends its deepest sympathies to the household and family members of Charlie Marriage.
“We are going to rigorously take into account the problems raised in a Prevention of Future Deaths Report by HM Coroner upon receipt and can reply in the end.”
Medical director of DHU Healthcare Aqib Bhatti added: “DHU Healthcare extends its deepest sympathies to Mr. Marriage’s household and family members throughout what we respect is an extremely troublesome time.
“We stay devoted to making sure affected person security and well timed entry to care.
“We’re rigorously reviewing the coroner’s findings and, as a commissioned service, will work carefully with NHS England and different companions to handle the suggestions.”
The Solar has additionally Superdrug for remark.
A spokesperson for Superdrug informed The i: “Our ideas and condolences are with Mr Marriage’s household.
“The protection and well-being of our sufferers stay our high precedence. We take all needed steps to make sure the best requirements of service are upheld always.
“The impartial locum pharmacist concerned on this case not works with us.”
Henrietta fears that different individuals who discover themselves with out important meds out of enterprise hours might meet the identical tragic destiny as Charlie.
Will Marriage, Charlie’s father, stated: “We are able to’t do something about Charlie now. We’re all very unhappy about it.
“But when something good can come out of this, if it might imply another person sooner or later doesn’t need to have these waits and people difficulties in getting needed remedy then that will be actually useful.”
