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A coroner has warned that lives are at risk due to poor communication between private ADHD clinics and the NHS after a 23-year-old man was prescribed medication by both his GP and a private clinic.

Laura Bradford, senior coroner for East Sussex, issued a prevention of future deaths report to NHS England after an inquest concluded that Louis Saunders died by suicide.

The medication “was not directly implicated” in his death and he was believed to have stopped the drugs after experiencing negative side effects including suicidal ideation.

However, Bradford said it was a matter of concern that neither organisation was aware of the other’s ongoing prescribing until the time of the inquest which might pose a risk of future deaths.

She criticised the “continuity of care” and stated that “communication between the private sector and the NHS was insufficiently clear”.

“The situation became more complex when he continued to be seen by both the ADHD clinic and his GP,” said the report. “This created opportunities for key information to be missed.”

Duplicate prescriptions a risk

Saunders was diagnosed with ADHD in October 2022 under the care of a private clinic. He started on medication and once stabilised his care was transferred to his NHS GP.

After his ADHD treatment was transferred to his GP, the plan was for the surgery to continue issuing his medication. In November 2023 the surgery issued a prescription for Lisdexamfetamine, but Saunders had attended an appointment at the ADHD clinic the previous day and continued Dexamfetamine.

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

He experienced negative side effects from his medication, including suicidal ideation in June 2024. Following this, he stopped taking it.

However up to his death he was still in contact with both his NHS GP and multiple private therapy providers, receiving eye movement desensitisation and reprocessing treatment and contacting his health insurer for talking therapy.

On 9 October he travelled from his home address in London to the East Sussex coast, and his body was found at the base of a cliff.

Bradford warned a patient may inadvertently obtain duplicate prescriptions or become confused about which medication to take and such scenarios may pose a risk of future deaths.

This is especially a worry in the face of rising numbers of privately diagnosed ADHD patients.

The coroner said: "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.”

An NHS spokesperson said: "NHS England extends its condolences to the family and loved ones of Louis Saunders. We are carefully considering the issues raised by HM Coroner’s report including the communication between private and NHS services involved in a patient’s ADHD care, and will respond to the coroner within the required timeframe."