An inquest this week into the death of a student who suffered a fatal seizure having been unable to get his anti-epilepsy medication from a pharmacy found there were failings on the part of his GP, a locum pharmacist and NHS 111 call handlers.

Charlie Marriage died from sudden unexpected death in epilepsy during a seizure alone in his flat in Camberwell in June 2021. Last month, the inquest heard he spent three hours in a branch of Superdrug in Camberwell “begging” for his medicine Fycompa, which he relied on to manage his condition, because the locum did not tell him they were out of stock.

Giving evidence, Marriage’s mother, Henrietta Hastings, said she and her son went to the pharmacy to get the medication but claimed the locum was unable to access the referral for the medicine on the pharmacy’s computer.

She said they only realised the drug was out of stock after overhearing the locum telling an NHS 111 operator over the phone and insisted the “build-up of stress and anxiety” was a “massive trigger” for Marriage’s seizure and could have been avoided.

Marriage later took a lower dose of some out-of-date Fycompa at his girlfriend’s house and suffered the fatal seizure the following day.

He had gone to the pharmacy to get an emergency supply of medication having received a message from NHS Test and Trace telling him to self-isolate because of a risk of Covid.

Ms Hastings said he contacted his GP to request the medicine but was cut off, before he called back later and was told by the practice they would call him back. The inquest heard the call never came. Ms Hastings said her son then called the practice again and was told to go online and submit a request so the GP could issue an emergency prescription.

However, the practice had closed by time Marriage submitted the online request, so he called NHS 111. The inquest heard he made five calls to them and spoke to five different operators before NHS 111 told him to go the Superdrug in Camberwell to collect his medicine.

Laying out his verdict on Tuesday at London Inner South Coroner’s Court, the coroner Xavier Mooyaart said “there were a significant number of failings” and “many missed opportunities” leading up to Marriage’s death. However, Mooyaart did not say Marriage would still be alive if those failings had not happened.

According to The Sun, Mooyaart said the pharmacy made “a simple failure” by opening despite its inability to support patients needing emergency medicine and said the branch was two weeks behind on prescriptions.

Mooyaart also pointed to the failure of the locum pharmacist, who had just started working at the pharmacy, to access the online system which held Marriage’s NHS 111 referral. Mooyaart said the locum could have directed him to another pharmacy or A&E.

Superdrug told Independent Community Pharmacist the locum no longer works with them.

“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,” a Superdrug spokesperson said.