Lyn Maher

I am Rachel Knight H M Coroner, for the coroner area of South Wales Central.

On 31 January 2024 I commenced an investigation into the death of Lyn MAHER . The  investigation concluded at the end of the inquest on 15/01/2026. The conclusion of the  inquest was a narrative with the following cause of death: 1a        hyperkalaemia 1b        Statin-induced rhabdomyolysis following clarithromycin treatment for lower respiratory tract infection (contraindicated medication) 1c II         Dilated Ischaemic Cardiomyopathy and acute on chronic kidney disease

These were recorded as :-    Lyn Maher was aged 79 when on 3rd January 2024 she was prescribed clarithromycin for a chest  infection, and part of her usual medication regime was simvastatin for high cholesterol. There is a  well-known contraindication between these drugs. Lyn was not told to stop taking her statin by  either her GP, nor by a community pharmacist dispensing the drug. On 10th January, she was  issued with a further prescription for the same drug and again she was not told to stop taking her  statin by GP nor a different community pharmacist. On 15th January Lyn was admitted to the Royal Glamorgan Hospital with a variety of symptoms and remained in hospital thereafter. At no point  was Lyn asked about whether she had co-ingested the drugs and her statin continued to be given.  Lyn’s condition continued to deteriorate, and she became so weak she could not use her legs and  could barely lift a spoon to her mouth. There was a missed diagnosis of rhabdomyolysis. There were missed opportunities by GP, community pharmacists and hospital clinicians to identify  the co-ingestion of the contraindicated drugs. There were missed opportunities to stop the further  administration of the statin at hospital. There were missed opportunities to test the creatinine  kinase level which was undoubtedly rising. There was a missed diagnosis of rhabdomyolysis at  hospital. Each of these factors more than minimally contributed to Lyn’s tragic death which  occurred following a cardiac arrest due to hyperkalaemia on 23rd January 2024 The Inquest focused upon:- –           care and treatment from 3rd January 2024 until Lyn’s death on 23rd January 2024 –           Cause of death and the degree of contribution (if any) made by the concomitant ingestion of clarithromycin with simvastatin in the community, and the degree of contribution of  other factors at hospital or generally

During the course of the inquest the evidence revealed matters giving rise to concern. In  my opinion there is a risk that future deaths will occur unless action is taken. In the  circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. (1)  Evidence was heard that 2 separate community pharmacists did not tell Lyn, (nor pass a message via her family who collected the tablets), that she must stop taking simvastatin  during the course of the clarithromycin, required for her chest infection. The pharmacists  did not know she was taking simvastatin. 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. (2) I am concerned that there is confusion amongst community pharmacists in Wales  around the conflict between the expectation of safe prescribing/dispensing and patient  confidentiality (when someone other than the patient collects the medication). (3) I am concerned that community pharmacists in Wales only have very limited access to  the Welsh Clinical Portal, where they can see relevant drug history and recent test results,  which would enable them to properly and safely counsel patients to stop contraindicated  drugs (here simvastatin with clarithromycin) but applicable more widely. I heard evidence  that access to such information is available routinely in English pharmacies, but only in  exceptional circumstances in Wales. I have no understanding of why that is the case. (4) Here, had either community pharmacist had access to Lyn’s drug history, they would  have noted the contraindication and either told Lyn, her representative or written on the  pharmacy bag that she was to stop the simvastatin. This likely would have changed the  outcome for Lyn.

In my opinion action should be taken to prevent future deaths and I believe you and your organisation have the power to take such action.