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Poor communication between private clinics and NHS doctors is putting patients with attention deficit hyperactivity disorder (ADHD) at risk of receiving duplicate prescription medicines, a coroner has warned. 

During her inquest into the death of 23-year-old Louis Saunders, whose body was found at the bottom of a cliff in East Sussex on October 10, 2024, the county’s senior coroner Laura Bradford said he experienced negative side effects from his ADHD medication, including suicidal ideation. 

Two years earlier, Saunders was diagnosed with ADHD by a private clinic, which started him on medication and transferred his care to his GP through a shared care agreement.

At that point, the inquest heard, the plan was for his GP to continue issuing his medication and on November 6, 2023, his surgery issued a prescription for Lisdexamfetamine.

Neither organisation was aware of the other’s ongoing prescribing 

However, Saunders attended an appointment at the ADHD clinic the day before and the clinic’s notes showed he was to continue on Dexamfetamine. In her report, Bradford said: “Neither organisation was aware of the other’s ongoing prescribing until the time of the inquest.”

The coroner added: “Although the medications have similar names, they are distinct drugs with different dosing requirements. Effective management and titration are understood to be essential to ensure therapeutic benefit and limit adverse effects.”

The inquest heard that in June 2024, Saunders “mentioned he had thoughts of travelling to cliffs in East Sussex” and he stopped taking his medication. A post-mortem found no medication in his system.

However, the coroner’s report also said he was in contact with his GP and “multiple private therapy providers” between July and October 2024.

“He received eye movement desensitization and reprocessing treatment and contacted his health insurer to seek talking therapy during this time,” the report said.

Saunders contacted his health insurer on July 31, 2024, to get referred for further therapy. He received privately funded therapy over the next few months and the report noted his behaviour at that time was “changeable”.

Saunders made another call to his insurer on October 8, 2024, about therapy and he arranged a follow-up appointment. The next morning, he travelled from his home in London to the East Sussex coast and his car was found in a layby later that evening.

His backpack containing his belongings was found on the cliff edge the next day and his body was found at the bottom of the cliff.

Such scenarios may pose a risk of future deaths

“Although medication was not directly implicated in Louis’ death, there remains a risk that a patient may inadvertently obtain duplicate prescriptions or become confused about which medication to take,” the coroner said.

“Such scenarios may pose a risk of future deaths. As increasing numbers of patients are receiving ADHD diagnoses and commencing treatment in the private sector due to long NHS waiting times, I am concerned about the robustness of current processes to ensure safe and continuous care following transfer to a GP.”

Bradford gave NHS England until April 24 to set out what action it has taken or proposes to take to address the problem. Her report was also sent to Saunders’ family, the Royal Pharmaceutical Society, Royal College of Psychiatrists, Nuffield Health Wellbeing Service and the ADHD Taskforce.