A coroner has recommended that NHS England evaluate its procedures for managing patients with 'cliff edge conditions', including epilepsy and diabetes, following the sudden death of a South London student.

Charlie Marriage, a 32-year-old Brunel University student, died from sudden unexpected death in epilepsy (SUDEP) after being unable to obtain his necessary anti-epileptic medication.

Mr Marriage, who resided in Camberwell, had spent two days attempting to secure his medication before his death on June 27, 2021. Assistant Coroner for Inner South London, Xavier Mooyaart, announced his findings during an inquest into Mr Marriage's death.

Coroner Mooyaart highlighted the potential vulnerability of certain patient groups, including those with epilepsy, diabetes, and heart conditions, if they are unable to access their medications promptly.

The coroner suggested that NHS England, which oversees the majority of healthcare services in England, is in a pivotal position to evaluate and improve current systems to prevent similar tragedies.

He noted that his recommendations were not intended as criticisms but as necessary measures to prevent future deaths through better management and support for patients.

Prior to his death, Mr Marriage had managed to find some Fycompa, an anti-epileptic drug, at his girlfriend's house.

However, this medication was expired and taken in a lower dose than required.

Coroner Mooyaart indicated that the inadequate supply and dosage of Fycompa likely increased Mr Marriage's risk of a severe seizure.

The inquest identified multiple failures in the response of healthcare providers, including a doctor's surgery, a Superdrug pharmacy in Camberwell, and NHS 111, in assisting Mr Marriage with his medication needs.

Henrietta Hastings, Charlie's mother, mentioned during the inquest that Mr Marriage experienced significant stress and anxiety while trying to obtain his medication from Superdrug, where he and his mother spent three unsuccessful hours.

Compounding the issue, Mr Marriage had received a notification from NHS Test and Trace advising him to self-isolate due to potential Covid-19 exposure.

This prevented him from picking up a repeat prescription from his university pharmacy in Uxbridge.

Efforts to acquire an emergency supply through other local channels were also unsuccessful.

Despite making repeated calls to NHS 111 and visiting a local pharmacy, he could not secure his medication in time.

Coroner Mooyaart concluded that, although efforts were made to assist Mr Marriage, they ultimately proved ineffective, underscoring the need for systemic improvements in medication access and patient support.