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A coroner in Wales has found that the “very limited access” Welsh pharmacies have to patient records contributed to the 2024 death of a woman after several clinicians missed a “well-known contraindication” between her usual statins and clarithromycin. 

Lyn Maher died in hospital aged 79 on January 23, 2024 after several “missed opportunities,” wrote South Wales Central coroner Rachel Knight in a report to prevent future deaths published this Tuesday (February 3). 

When Ms Maher received prescriptions for clarithromycin to treat a chest infection on January 3 and January 10, 2024, neither her GP nor the community pharmacist who dispensed the antibiotic told her to stop taking her statin, which she took to treat high cholesterol and formed part of her usual medication regime. 

“The pharmacists did not know she was taking simvastatin,” wrote Ms Knight, raising concerns that community pharmacies in Wales “only have very limited access to the Welsh Clinical Portal”. 

Statins weren’t stopped

On January 15, 2024, five days after receiving her second prescription for clarithromycin, Ms Maher was admitted to the Royal Glamorgan Hospital “with a variety of symptoms”.

“At no point was Lyn asked whether she had co-ingested the drugs,” wrote the coroner, adding: “Her statin continued to be given.”

Ms Maher’s condition continued to deteriorate, causing her to “become so weak she could not use her legs and could barely lift a spoon to her mouth,” the inquest found.

Ms Knight found that after Ms Maher was admitted to hospital “there were missed opportunities to test the creatinine kinase level, which was undoubtedly rising”.

There was also a missed diagnosis of rhabdomyolysis.

The coroner found each of these “missed opportunities” contributed “more than minimally” to her death, which was attributed to hyperkalaemia, statin-induced rhabdomyolysis following the contraindicated clarithromycin treatment, dilated ischaemic cardiomyopathy and acute onset kidney disease. 

‘Confusion’ over clinical checks

The coroner questioned why community pharmacies in Wales are not provided with comprehensive record access to allow them to see a patient’s drug history and “enable them to properly and safely counsel patients to stop contraindicated drugs”.

She added: “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.” 

Read-only access to GP Connect patient records was rolled out to pharmacies in England in March 2025.  

Ms Knight wrote: “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.” 

She also identified what she described as “confusion among 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”.  

Ms Knight added: “Had either community pharmacist had access to Lyn’s drug history, they would have noted the contraindication and either told Lyn [or] her representative, or written on the pharmacy bag that she was to stop the simvastatin. 

“This likely would have changed the outcome for Lyn.”

The report was sent to Welsh health minister Jeremy Miles, the General Pharmaceutical Council and Digital Health and Care Wales chief executive Helent Thomas, all of whom are required to respond to the coroner by March 31.

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